Claims Processing Systems Modification | Innovative Resources for Payors

42 REV.CD.

43 DESCRIPTION

44 HCPCS/RATES

45 SERV.DATE

46 SERV.UNITS

47 TOTAL CHARGES

1900050

070100

CHAPTER II: CLAIMS PROCESSING SYSTEMS MODIFICATION OBJECTIVE Services Included within the scope of the hospital outpatient pps Services Excluded from the scope of services paid under the hospital outpatient pps OUTPATIENT PROSPECTIVE PAYMENT SYSTEM BILL TYPES LINE ITEM DATES OF SERVICE REPORTING OF SERVICE UNITS DISCONTINUATION OF BILL TYPE 83X FOR SERVICES PAID UNDER OUTPATIENT PPS HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) HCPCS/Revenue Code Chart Reporting of HCPCS Codes Coding for Clinic and Emergency Visits Radiation Therapy Implanted DME and Prosthetic Devices and Diagnostic Devices and Implanted Diagnostic Devices MODIFIERS Special Guidelines for Using Modifiers with Radiology Services Modifier for Bilateral Procedures 50 Bilateral Procedure Payment Implications Modifiers for Discontinued Services 52 Reduced Services Special guidelines for Modifier 52 Payment Implications Additional Instructions for Coding Discontinued Surgical Services Modifier for Distinct Procedures Modifiers for Repeat Procedures Additional Guidelines for Coding Repeat Procedures Modifier for Evaluation and Management Services Modifier for Staged or Related Procedures Modifier for a Return Trip to the Operating Room Modifier for an Unrelated Procedure during a Postoperative Period HCPCS Level II Modifiers Guidelines for Level II Modifiers Level II Modifiers Condition Code G0 (zero) OBSERVATION AND EMERGENCY ROOM Emergency Room HOSPITAL INPATIENT SERVICES COVERED UNDER PART B Inpatient Part B Services – (Bill type 12x) Changes to Billing Procedures for Inpatient Part B and Outpatient Hospital Services BILLING CHANGES FOR CMHC AND PARTIAL HOSPITALIZATION SERVICES Billing Requirements Reporting of Service Units Line Item Date of Service Reporting Professional Services provided to Partial Hospitalization Patients: Payment Provider Reporting Requirements Professional Component Corneal Tissue Acquisition Costs CONDITION CODES 20 AND 21 Repetitive Services PROCEDURES FOR SUBMITTING LATE CHARGES VS. ADJUSTMENTS Payment under Outpatient Prospective Payment System(OPPS) for Certain Services Provided in Various Settings Site MISCELLANEOUS ISSUES Designated Drugs or Biologicals Designated Devices Process for Identifying Items Potentially Eligible for Payment as New Technologies or Pass-Throughs Process for Obtaining HCPCS Codes Outliers PROGRAM MANUALS ON THE INTERNET

CPT five-digit codes, descriptions, and all other data only are copyright 1999 Americal Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dipense medical services. AMA assumes no liability for data contained or not contained herein.

CHAPTER II: CLAIMS PROCESSING SYSYEM MODIFICATION OBJECTIVE This chapter provides participants with an overview of the claims processing system and billing changes under the outpatient prospective payment system

Services Included within the scope of the hospital outpatient pps

The following services are included in the scope of hospital outpatient PPS:

Certain services for patients who have exhausted their Part A benefits
Partial hospitalization services for CMCHs
Services designated by the Secretary: surgical procedures, radiology (including radiation therapy), clinic visits, partial hospitalization for the mentally ill, surgical pathology and cancer chemotherapy
Specific hospital outpatient services furnished to a beneficiary who is admitted to a Medicare-participating SNF, but who is not considered to be a SNF resident for purposes of SNF consolidated billing, with respect to those services that are beyond the scope of SNF comprehensive care plans
Certain preventive services furnished to healthy persons, e.g., colorectal screening
Hospital outpatient PPS for certain medical and other health services when they are furnished by other providers, such as CORFS, and HHAs, or to hospice patients for the treatment of a non-terminal illness.
Implants

Services Excluded from the scope of services paid under the hospital outpatient pps

The following services are excluded from the scope of services paid under outpatient PPS:

Services already paid under fee schedules or other payment systems including, but not limited to:
Screening mammographies
ESRD paid under the ESRD composite rate
Professional services of physicians and non-physicians paid under the Medicare physician fee schedule
Laboratory services paid under the clinical diagnostic laboratory fee schedule
Non-implantable DME, orthotics, prosthetics and prosthetic devices, prosthetic implants, and take-home surgical dressings paid under the DMEPOS fee schedule
Hospital outpatient services furnished to SNF inpatients as part of his or her resident assessment or comprehensive care plan
Services and procedures that require inpatient care
Ambulance services, physical and occupational therapy, and speech/language services
Drugs and supplies that are used within a dialysis session where payment is not included in the composite rate
Take-home surgical dressings paid under the DMEPOS fee schedule

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM BILL TYPES

The bill type is a code indicating the specific type of bill (inpatient, outpatient, adjustments, cancels, late charges). This is a three-position field and is mandatory for all outpatient bills paid under the Outpatient Prospective Payment System (OPPS).

The three-digit alphanumeric code gives three specific pieces of information. The first digit identifies the type of facility. The second classifies the type of care. The third indicates the sequence of this bill in this particular episode of care: it is referred to as the frequency code.

Data elements in the HCFA uniform billing specifications are consistent with the Form HCFA-1450. The type of bill is located in field 4 of the 1450. In the electronic specifications, the bill type is located in record type 40, position 25.

The bill types that will be affected by Outpatient Prospective Payment System are:

12x	Hospital Inpatient (Part B)
13x	Hospital Outpatient with CC 41
13x	Hospital Outpatient
14x	Hospital Referenced Diagnostics
34x	Home Health Agency (HHA)
75x	Comprehensive Outpatient Rehabilitation Facility (CORF)
76x	Community Mental Health Center (CMHC)

LINE ITEM DATES OF SERVICE

Under the hospital OPPS, hospitals and CMHCS are required to report all services utilizing HCPCS coding in order to assure proper payment. This requirement applies to:

Acute care hospitals
Hospital outpatient departments
Community mental health centers
Comprehensive outpatient rehabilitation facilities
Home Health Agencies
Hospice patients for the treatment of a non-terminal illness

Under OPPS, line item dates of service are to be reported on all outpatient bills for each line where a HCPCS code is required, including claims where the "from" and "through" dates are the same.

Claims will be returned to providers if submitted

With a HCPCS and no corresponding line item date of service, or
With a line item date of service outside the ‘statement covers’ period
Line item dates of service and no HCPCS code

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES
*250*				1	*200*	00
*510*		*92002*	*070100*	1	*100*	00
*519*		*95805*	*070100*	1	*200*	00
*510*		*92002*	*070100*	1	*300*	00
*943*		*93797*	*070100*	1	*500*	00
*943*		*93797*	*070100*	1	*500*	00

REPORTING OF SERVICE UNITS

The definition of service units is revised for hospital outpatient services and CMHCS where HCPCS code reporting is required.

A unit is now redefined as the "number of times the service or procedure being reported was performed according to the HCPCS code definition."

EXAMPLE: If the following procedures are performed once on a specific date of service, the entry in the "service units" field is as follows:

90849	Multiple-family group psychotherapy	Units = 1
92265	Needle oculoelectro-myography, one or more extraocular muscles, one or both eyes, with interpretation and report	Units = 1
95004	Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, specify number of tests	Units = number of tests performed
95861	Needle electromyography two extremities with or without related paraspinal areas	Units = 1

EXAMPLE: If the HCPCS code has a 15-minute element, the entry in the service units field is as follows:

97530	Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes	1 unit 8 min. to >23 min.
		2 units 23 min. to <38 min.
		3 units 38 min. to <53 min.
		4 units 53 min. to <68 min.
		5 units 68 min. to <83 min.
		6 units 83 min. to < 98 min.
		7 units 98 min. to <113 min.
		8 units 113 min. to <128 min.

The pattern remains the same for treatment times in excess of two hours. Hospitals should not bill for services performed for less than 8 minutes. The expectation is that a provider’s time for each unit will average 15 minutes in length.

The beginning and ending time of the treatment should be recorded in the patient’s medical record along with the note describing the treatment. (The total length of the treatment to the minute could be recorded instead.)

If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time.

For example, if 24 minutes of 97112 and 23 minutes of 97110 were furnished, then the total treatment time was 47 minutes; therefore, only three units can be billed for the treatment. The correct coding is two units of 97112 and one unit of 97110; thus assigning more units to the service that took more time.

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*420*		*97112*	*070100*	2	*500*	00
*420*		*97110*	*070100*	1	*300*	00

Claims that do not contain service units for a given HCPCS code will be returned to the provider

DISCONTINUATION OF BILL TYPE 83X FOR SERVICES PAID UNDER OUTPATIENT PPS

Effective for dates of service July 1, 2000 and after, bill type 83x (ambulatory surgery center or ASC) will no longer be used for hospital ambulatory surgical claims. Hospitals must use 13x for ambulatory surgical claims submitted for outpatient prospective payment system (OPPS) payment. Claims submitted with bill type 13x will no longer be changed to 831 by the claims processing system.

The requirement to submit all charges for ASC services on the same claim has not changed. However, if preoperative lab services are included on the claim, the "from" date of the claim must include the date of the pre-op lab services.

In the field "statement covers period from date" ( 1450 form locator 6), enter the earliest date services were rendered.
Preoperative laboratory services must always have a line item date of service within the "from" and "thru" dates on the claim.
Include all related services on one claim. An adjustment must be submitted if all services were not included on the original claim. Late charge bills (XX5) are no longer acceptable.
Indian Health Services providers continue to bill surgeries utilizing bill type 83x.

Critical Access providers continue to bill surgeries utilizing bill type 85X. bill type.

HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS)

In preparation for implementation of the hospital OPPS, hospitals and CMHCs are required to report services using HCPCS coding in order to receive proper outpatient payment. There are three levels of HCPCS codes:

Level I codes contain the American Medical Association’s Current Procedural Terminology (CPT) coding system. This level consists of all numeric codes.
Level II codes (national codes) contain the codes for physician and non-physician services which are not included in CPT 4 codes, (e.g., ambulance , DME, orthotics and prosthetics). These are alphanumeric codes maintained jointly by HCFA, Blue Cross and Blue Shield Association and the Health Insurance Association of America (HIAA).
Level III (local codes) contain the codes that Medicare fiscal intermediaries and carriers develop as needed.

There are certain HCPCS codes that are not used by Medicare. If hospitals report them on a claim with other services that are covered, the intermediary will deny the line item as non-covered.

HCPCS/Revenue Code Chart

The following chart represents all HCPCS coding to be reported and paid under the OPPS system.

*Revenue codes have not been identified for these procedures, as they can be performed in a number of revenue centers within a hospital, such as emergency room (450), operating room (360), or clinic (510). Providers are to report these HCPCS codes under the revenue center where they were performed.

The listing of HCPCS codes contained in the chart does not assure coverage of the specific service. Current coverage criteria applies.

It is intended to be used as a guide by hospitals to assist them in reporting services rendered. NOTE: this chart does not represent all HCPCS coding subject to OPPS but will be expanded at a later date.

* Please refer to page 48 for PHP codes.

Revenue Code	HCPCS Code	Description
*	10040-69990	Surgical Procedure
*	92950-92961	Cardiovascular
*	96570, 96571	Photodynamic Therapy
*	99170, 99185-99186	Other Services and Procedures
*	99291-99292	Critical Care
*	99440	Newborn Care
*	90782-90799	Therapeutic or Diagnostic Injections
*	D1050, D0240-D0274, D0277, D0460, D0472-D0999, D1510-D1550, D2970, D2999, D3460, D3999, D4260-D4264, D4270-D4273, D4355-D4381, D5911-D5912, D5983-D5985, D5987, D6920, D7110-D7260, D7291, D7940, D9630, D9930, D9940, D9950-D9952	Dental Services
*	92502-92596, 92599	Otorhinolaryngologic Services (ENT)
278	E0749, E0782-E0783, E0785	Implanted Durable Medical Equipment
278	E0751, E0753, L8600, L8603, L8610, L8612, L8614, L8619, L8630, L8641-L8642, L8658, L8670, L8699	Implanted Prosthetic Devices
302	86485-86586	Immunology
305	85060-85102, 86077-86079	Hematology
31X	80500-80502	Pathology – Lab
310	88300-88365, 88399	Surgical Pathology
311	88104-88125, 88160-88199	Cytopathology
32X	70010-76999	Diagnostic Radiology
333	77261-77799	Radiation Oncology
34X	78000-79999	Nuclear Medicine
37X	99141-99142	Anesthesia
413	99183	Other Services and Procedures
45X	99281-99285	Emergency
46X	94010-94799	Pulmonary Function
480	93600-93790, 93799, G0166	Intra Electrophysiological Procedures and Other Vascular Studies
481	93501-93571	Cardiac Catheterization
482	93015-93024	Stress Test
483	93303-93350	Echocardiography
51X	92002-92499	Opththalmological Services
51X	99201,99215,99241-99245,99271-99275	Clinic Visit

510, 517, 519	95144-95149,95163,95170, 95180,95199	Allergen Immunotherapy
519	95805-95811	Sleep Testing
530	98925-98929	Osteopathic Manipulative Procedures
636	A4642, A9500, A9605	Radionclides
636	90296-90379, 90385, 90389-90396	Immune Globulins
636	90476-90665, 90675-90749	Vaccines, Toxoids
73X	G0004-G0006, G0015	Event Recording ECG
730	93005-93014, 93040-93224, 93278	Electrocardiograms (ECGs)
731	93225-93272	Holter Monitor
74X	95812-95827, 95950-95962	Electroencephalo-gram (EEG)
762	99217-99220	Observation
771	G0008-G0010	Vaccine Administration
88X	90935-90999	Non-ESRD Dialysis
901	90870-90871	Psychiatry
903	90812-90815, 90823-90824, 90826-90829, 90910-90911,	Psychiatry
909	90880	Psychiatry
910	90801-90802, 90865, 90899	Psychiatry
914	90804-90809, 90816-90819, 90821, 90822, 90845, 90862	Psychiatry
915	90853, 90857	Psychiatry
916	90846-90847, 90849	Psychiatry
917	90901-90911	Biofeedback
918	96100-96117	Central Nervous System Assessments/Tests
92X	95829-95857, 95900-95937, 95970-95999	Miscellaneous Neurological Procedures
920, 929	93875-93990	Non Invasive Vascular Diagnosis Studies
922	95858-95875	Electromyography (EMG)
924	95004-95078	Allergy Test
940	96900-96999	Special Dermatological Procedures
940	98940-98942	Chiropractic Manipulative Treatment
940	99195	Other Services and Procedures
943	93797-93798	Cardiac Rehabilitation

Reporting of HCPCS Codes

Under OPPS, when basing payment on CPT codes, the range of cost reflects hospitals’ billing patterns in increasing levels of intensity. Increasing increments are due largely to hospitals’ use of ‘chargemaster’ systems, which generate bills using predetermined charges for codes.

Hospitals should not use the lowest level code (e.g., CPT code 99201) to bill for all clinic visits. This would distort the data causing inflation in both the volume and cost of low-level clinic visits.

It is important that hospitals use the appropriate level of intensity of their clinic visits and reporting codes properly based on internal assessment of the charges for those codes rather than failing to distinguish between low- and mid-level visits because the payment is the same.

The billing information that hospitals report during the first years of implementation of OPPS will be vitally important to the revision of weights and other adjustments that affect payment in future years.

Each facility will be accountable for following its own system for assigning the different level of HCPCS codes.

HCPCS Code 99291

Hospitals can use HCPCS code 99291 in place of, but not in addition to, a code for a medical visit/service in a clinic, emergency department.

The CPT definition of ‘critical care’ is the evaluation and management of a critically injured patient who requires periods of continual attendance of a physician.

Coding for Clinic and Emergency Visits

Prior to OPPS, hospitals could report CPT code 99201 to indicate a visit of any type. Under OPPS, 31 codes are used to indicate visits with payment differentials for more or less intense service. Hospitals should code the visit using the following HCPCS codes:

92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204,99205,99211,99212,99213,99214,99215,99241,

99242,99243,99244,99245,99271,99272,99273,99274,

99275,99281,99282,99283,99284,99285,G0101 and G0175.

Hospitals should use CPT guidelines when applicable or crosswalk hospital coding structures to CPT codes. For example, a hospital that has 8 levels of emergency and trauma care depending on nursing ratios should walk those 8 levels to the CPT codes for emergency care.

HCPCS Code G0175

Hospitals can use HCPCS code G0175 in reporting a scheduled medical conference with the patient involving a combination of at least three health care professionals, and one of whom is a physician, but cannot be nurse.

Sterotatic Radiotherapy

Two new HCPCS codes have been developed to report radiation therapy in place of HCPCS code 61793.

Providers should use these codes beginning with dates of service July 1, 2000.

G0173 stereotactic radiosurgery, complete course of therapy in one session.
G0174 stereotactic radiosurgery, requiring more than one session.

Initially, both codes will pay the same however, expect differences in cost to become apparent during the first year or 18 months of OPPS.

Implanted DME and Prosthetic Devices and Diagnostic Devices and Implanted Diagnostic Devices

Implanted Durable Medical Equipment (DME) and implanted prosthetic devices are now paid under the Outpatient Prospective Payment System and no longer paid on fee schedule. The following are the appropriate HCPCS codes for payment under OPPS. Do not bill your local carrier for dates of service on and after July 1, 2000.

Implanted DME

E0749

E0782

E0783

E0785

Implanted

Diagnostic Devices

C1361

Implanted Prosthetic Devices
E0751	E0753
L8600	L8603
L8610	L8612
L8613	L8614
L8630	L8641
L8642	L8658
L8670	L8699

MODIFIERS

A modifier is a two position alpha or numeric code that is added to the end of a HCPCS code to clarify the services being billed.

Modifiers provide a means by which a service can be altered without changing the procedure code. They add more information, such as the anatomical site, to the HCPCS code. In addition, they help to eliminate the appearance of duplicate billing and unbundling.

There are CPT-4 and Level II HCPCS modifiers. They are used to increase accuracy in reimbursement, coding consistency, editing, and to capture payment data. Billing accurately with modifiers is an integral part of the OPPS.

Use the modifiers identified below, when appropriate, for surgical procedures (HCPCS codes 10000–69999), radiology (HCPCS codes 70010–79999), and other diagnostic procedures (HCPCS codes 90700–99199).

Not all HCPCS codes will require modifiers

Do not use a modifier to indicate an anatomical site location on body (modifier 50 or Level II modifiers) if the narrative definition of a code indicates multiple occurrences.

EXAMPLE: The code definition indicates two to four lesions.

11056 – Paring or cutting hyperkeratolic lesion, leg (e.g., corn or callous); two or four lesions. The code definition indicates multiple lesions.

73565 – Radiologic examination; both knees, standing, anteroposterior. The code definition indicates the specific site.

Do not use a modifier to indicate an anatomic site (modifier 50 or Level II modifiers) if the narrative definition of a code indicates the procedure applies to more than two sites.

EXAMPLE: Code 11600 (Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or less)

Special Guidelines for Using Modifiers with Radiology Services

Use modifiers 50, 52, 59,, 76, 77, and level II modifiers.
Do not report a radiology procedure that was canceled.

Modifier for Bilateral Procedures

50 Bilateral Procedure

Modifier 50 is used to report bilateral procedures that are performed at the same session. Report the appropriate HCPCS code and add the modifier 50 to the procedure code to identify that the procedure was performed on a contralateral site. Units should be reported as one.

EXAMPLE: Procedure 19000 (Puncture aspiration of cyst of breast) was performed on the right and left breast during the same operative session. This is billed as 1900050.

Use modifier 50 for;

surgical procedures (CPT 10000-69990)
radiology procedure if applicable
any bilateral procedure performed on both sides at the same session

Do not use modifier 50 for:

procedures identified by their terminology as "bilateral," e.g., 27395 (Lengthening of hamstring tendon, multiple, bilateral)
procedures identified as "unilateral or bilateral," e.g., 52290 (Cystourethroscopy, with meatotomy, unilateral or bilateral)

Do not:

submit two line items to report a bilateral procedure
submit with modifiers RT and LT when modifier 50 applies

Payment Implications

When modifier 50 is reported, reimbursement is for two procedures: PRICER will apply the rules for calculating payment for multiple procedures. The provider is Reimbursement at 150% of the group rate.
Radiology is reimbursed at 200%. (Reimbursed is for two procedures)

Modifiers for Discontinued Services

52 Reduced Services

Modifier 52 is for radiology and other diagnostic procedures. It can also be used for surgery when the use of anesthesia was not an inherent part of performing the procedure.

Example: If a colonoscopy, HCPCS code 45378, flexible, promimal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) was started (conscious sedation had been administered), but is was found that the patient was inadequately prepped for the procedure, so the procedure was discontinued, and no exam of even the sigmoid was possible. This should be billed as 4537852

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*		*4538752*	*070100*	1	*500*	00

*Revenue code should be billed where the services were performed.

However, it is not appropriate to use modifier 52 if a portion of the intended procedure was completed and a code exists which represents the completed portion of the intended procedure.

Example: If a colonoscopy, HCPCS code 45378, was partially completed, that is, the colonoscopy was advanced as far as the splenic flexion, to the extent that the procedure meets the definition of a sigmoidoscopy, HCPCS code 45330, it is appropriate to bill that code. Otherwise, if no codes exists for what has been done, report the intended code with modifier 52.

Special guidelines for Modifier 52

Code to the extent of the procedure that was performed and do not use modifier 52
If no code exists for what has been done, report the intended code with modifier 52

73 Discontinued Outpatient Hospital Surgical Procedure (ASC) or Diagnostic Procedure/Service Prior to the Administration of Anesthesia

Modifier 73 is used for surgical procedures for which anesthesia (general, regional, or local) is planned.

EXAMPLE: A patient is prepared for procedure 49590 "repair spigelian hernia". Before anesthesia is administered, the physician decides the procedure should not be performed. This is billed as 4959073.

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*360*		*4959073*	*070100*	1	*400*	00

Use modifier 73 for:

procedures requiring anesthesia
an outpatient hospital procedure discontinued

- after the patient has been prepared for the procedure and/or

- before the induction of anesthesia (e.g., local, regional block(s) or general anesthesia)

Do Not:

use modifiers 52 and 73 together

Payment Implications

A terminated procedure with modifier 73 will be discounted at 50%

74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure or Diagnostic Procedure or Service after the Administration of Anesthesia

Modifier 74 is used for surgical procedures for which anesthesia (general,regional or local) has been started.

Example: Anesthesia for procedure 38745 (Axillary lymphadenectomy: complete is given and the procedure has been started, but the physician terminates the procedure before it is complete. This is billed as 3874574.

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*360*		*3874574*	*070100*	1	*800*	00

Use modifier 74 for:

procedures requiring anesthesia
an outpatient hospital/ambulatory surgery center (ASC) or diagnostic procedure discontinued after the administration of anesthesia

Additional Instructions for Coding Discontinued Surgical Services

When multiple procedures were planned and there was a termination:

If one of more of the procedures were completed, report the completed procedure(s) as usual. The other(s) planned and not started are not reported.
If none of the planned procedures were completed, report the first procedure that was planned with modifier 73 or modifier 74. The others are not reported.

Modifier for Distinct Procedures

59 Distinct Procedural Services

Modifier 59 is used for procedures/services that are not normally reported together, but may be performed under certain circumstances.

EXAMPLE: Procedures 23030 (Incision and drainage, shoulder area; deep abscess or hematoma) and 20103 (Exploration of penetrating wound; extremity) are performed on the same patient on the same date of service. The incision and drainage of the shoulder is the definitive procedure and any exploration of the area preceding this is considered an inherent part of the procedure. However, the exploration procedure was conducted on a different part of the same limb, adding the 59 modifier to code 23030 will explain the circumstance and prevent denial of the service. If these two codes were billed together without modifier 59, code 20103 would be denied.

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*360*		*23030*	*070100*	1	*800*	00
*360*		*2010359*	*070100*	1	*800*	00

Use modifier 59 for:

Indicating that a procedure or service was distinct or independent from other services performed on the same day.
Representing

different procedure or surgery,

different site or organ system,
separate incision, or
separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician
different session or patient encounter

Do not use modifier 59 if:

a level II HCPCS modifier can be used to indicate different body areas

Modifiers for Repeat Procedures

76 Repeat Procedure by the Same Physician

Modifier 76 is used to indicate that a procedure or service was repeated in a separate session on the same day by the same physician. This modifier may be reported for services ordered by physicians but performed by technicians. The procedure code is listed once and then listed again with modifier 76 added (two line items). The number of times that the procedure was repeated is reported on separate lines.

Example: EKG 93005 (Electrocardiogram, routine EKG with at least 12 leads; with interpretation and report) is performed at 8 a.m. An EKG, 93005 is ordered and repeated at 1 p.m. The patient’s condition requires another EKG, the physician orders it and the EKG is done at 10 p.m. This is billed as 93005, one unit (first line) and 9300576, two units (next line).

Diagnostic Test

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*730*		*93005*	*070100*	1	*300*	00
*730*		*9300576*	*070100*	2	*600*	00

For surgical procedures, report the HCPCS code without modifier 76 to indicate the first time the procedure was performed. For each additional time the procedure was performed, the HCPCS code is repeated with modifier 76 added. Do not use the units field to indicate that the procedure was repeated more than once on the same day.

EXAMPLE: Procedure 26615 open treatment of metacarpal fracture, single, with or without internal or external fixation,each bone. Later, while in the recovery room the internal fixation pin is dislodged, so that the operating surgeon needs to repeat the procedure. This is reported as 26615 (first line) and 2661576 (next line). Both will have units reported as one.

Surgical Procedure

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*360*		*26615*	*070100*	1	*200*	00
*360*		*2661576*	*070100*	1	*200*	00

77 Repeat Procedure by Another Physician

Modifier 77 is used for a procedure performed that had to be repeated by a different physician in a separate session on the same day. The procedure code is listed once and then listed again with modifier 77 added. The number of times the procedure was repeated is reported on separate lines. Do not use the units field to indicate that the procedure was performed more than once on the same day.

For surgical procedures, report the HCPCS code without modifier 77 to indicate the first time the procedure was performed. For each additional time the procedure was performed, the HCPCS code is repeated with modifier 77 added. Do not use the units field to indicate that the procedure was performed more than once on the same day.

Example: Procedure 26615 Open treatment of metacarpal fracture, single, with or without internal or external fixation, each bone. Later, while in the recovery room the internal fixation pin is dislodged, and a different surgeon repeats the procedure. This is reported as 26615 (first line) and 2661577 (next line). Both will have units reported as one. The only difference is that a different physician repeats the procedure so that modifier 77 is used in place of 76.

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*360*		*26615*	*070100*	1	*200*	00
*360*		*2661577*	*070100*	1	*200*	00

Additional Guidelines for Coding Repeat Procedures

Modifiers 76 and 77

If you are not sure who ordered the second procedure, or whether the same physician ordered both procedures, code based on the physician who performed the procedures.
The procedure repeated must be the same procedure.

Modifier for Evaluation and Management Services

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure of Other Service

Modifier 25 is billed with an evaluation and management (E & M) code to indicate that on the same day a procedure was performed, the patient’s condition required a significant, separately identifiable E & M service (even though the E & M service may be necessary because of the symptom or condition for which the procedure was provided).

Use modifier 25 for an E & M service:

that is above and beyond the procedure performed
that is beyond the usual pre-operative and post-operative care associated with the procedure
when a separate history was taken, a separate physical was performed, and a separate medical decision was made and is documented in the medical record

Modifier for Staged or Related Procedures

A Staged Or Related Procedure Or Service By The Same Physician During The Postoperative

Period On the Same Day

An example of modifier 58 is one were a needle biopsy is performed in the morning and the plan, which subsequently carried out, is to perform an excisional biopsy later in the day depending on the results of the surgical pathology report. The post operative period refers to same calender day

planned prospectively at the time of the original procedure (staged)
more extensive than the original procedure
for therapy following a diagnostic surgical procedure

Do not use modifier 58 to report the treatment of a problem that requires a return to the operating room (see modifier 78).

Modifier for a Return Trip to the Operating Room

78 Return to the Operating Room for a Related Procedure during the Postoperative Period

Modifier 78 is used to indicate that another procedure was performed during the postoperative period of the initital procedure that was performed earlier in the same day.

Example;: Procedure 23500, Closed treatment of clavicular fracture with manipulation; and following this it is subsequently decided that another procedure is required, such as 23515, ( open treatment of clavicular fracture, with or without internal or external fixation. This is reported as 23500 on the first line and 2351578 on the next line.)

When reporting surgical procedures, each revenue code must have charges associated with the revenue code reported.

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*360*		*23500*	*070100*	1	*300*	00
*360*		*2351578*	*070100*	1	*300*	00

Use modifier 78 if:

the subsequent procedure relates to the first procedure; and

the subsequent procedure requires the use of an operating room.

Modifier for an Unrelated Procedure during a Postoperative Period

79 Unrelated Procedure or Service by the Same Physician during a Postoperative Period

Modifier 79 is used to indicate that the performance of a procedure or service by the same physician during the post-operative period was unrelated to the original procedure that was performed earlier in the day.

EXAMPLE: Procedure 20100 (Exporation of penetrating wound, separate procedure; extremity followed later in the day by procedure 43227 esophagoscopy, rigid or flexible with control bleeding, any method.

42 REV.CD.	43 DESCRIPTION	44 HCPCS/RATES	45 SERV.DATE	46 SERV.UNITS	47 TOTAL CHARGES

*360*		*20100*	*070100*	1	*800*	00
*360*		*4322779*	*070100*	1	*800*	00

HCPCS Level II Modifiers

The following HCPCS level II modifiers are added, as appropriate, primarily to codes for procedures performed paired organs etc., on eyelids, fingers, toes, or arteries. These modifiers are used to prevent erroneous denials when duplicate HCPCS codes are billed to report separate procedures performed on different anatomical sites or different sides of the body.

Guidelines for Level II Modifiers

When a modifier is needed, the most specific modifier should be used first.

EXAMPLE: Use modifier E1 for the upper left eyelid, instead of modifier LT.

If more than one level II modifier applies, repeat the HCPCS code on another line with the appropriate level II modifier.

EXAMPLE: Code 26010 (drainage of finger abscess; simple) done on the left hand thumb and second finger would be billed: 26010FA (one line) and 26010F1 (separate line).

Modifiers LT and RT

- Apply to codes that identify procedures which can be performed on a contralateral anatomic sites (joints, bones) or on paired organs, extremities and, e.g., ears, eyes, nasal passages kidneys, lungs, ureters and ovaries

- Required when the procedure is performed on only one side, to identify the side operated upon

Level II Modifiers

E1 Upper left, eyelid E2 Lower left, eyelid E3 Upper right, eyelid E4 Lower right, eyelid FA Left hand, thumb F1 Left hand, second digit F2 Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit F5 Right hand, thumb F6 Right hand, second digit F7 Right hand, third digit F8 Right hand, fourth digit F9 Right hand, fifth digit	LC Left circumflex coronary artery (Hospitals use with codes 92980–92982, 92995, and 92996) LD Left anterior descending coronary artery (Hospitals use with codes 92980–92982, 92995, and 92996) LT Left side (used to identify procedures performed on the left side of the body) RC Right coronary artery (Use with codes 92980–92982, 92995, and 92996.) RT Right side (used to identify procedures performed on the right side of the body)	TA Left foot, great toe T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, fourth digit T4 Left foot, fifth digit T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit T8 Right foot, fourth digit T9 Right foot, fifth digit
Do not use modifiers LT and RT to report bilateral surgical procedures; use modifier 50 (Bilateral Procedure).

EXAMPLE:

Example Number	Right side?	Left side?	Same operative session?	Same doctor?	Repeat Procedure same day?	Code	Service Units
1	Y					XXXXXRT	1
2		Y				XXXXXLT	1
3	Y	Y	Y			XXXXX50	1
4	Y	Y	N			XXXXXRT XXXXXLT	1 1
5	Y	Y	Y	Y	Y, right side* only	XXXXX50 XXXXXRT76	1 1
6	Y	Y	Y	N	Y, right side* only	XXXXX50 XXXXXRT77	1 1
7	Y			Y	Y, right side* only	XXXXXRT XXXXXRT76	1 1
8	Y			N	Y, right side* only	XXXXXRT XXXXXRT77	1 1
(XXXXX represents the five-digit CPT-4 code) *Right side is used here for purposes of illustration only. For the left side, the modifier LT should be used instead of RT. Examples 4 through 8 above reflect very rare circumstances. The use of modifier 50 (bilateral) or RT and LT as described in the grid above only applies to CPT4 codes where "bilateral" is not already inherent in the CPT code description.

Service	HCPCS Range		Modifier		Modifier Description		Hints
Surgery	10000-69999		50		Bilateral Procedure		Use to report a procedure done bilaterally in same operative session. Use only for paired organs/body parts. Do not use if code indicates multiple occurrences. Do not use if the code indicates the procedure applies to different body parts. Do not use if code description included "bilateral" or "unilateral or bilateral."
			73		Discontinued Outpatient Hospital Procedure Prior to the Administration of Anesthesia		Use to report an outpatient procedure discontinued When the physician terminates the procedure After the patient is prepped for surgery and is in the surgery room, and Before anesthesia is delivered. If more than one procedure was planned, report only the procedure that was started.
			74		Discontinued Outpatient Hospital/Ambulatory Center (ASC) Procedure after the Administration of Anesthesia		Use to report an outpatient procedure discontinued When the physician terminates the procedure After anesthesia is delivered. If more than one procedure was planned, report only the procedure that was started.
			59		Distinct Procedural Service		Use for procedures not normally reported together. Use to indicate a procedure distinct or independent from other procedures performed on the same day. Use to represent (not ordinarily performed on the same day): Different procedure or surgery Different site or organ system Separate incision Separate injury (or area of injury in extensive injuries) Different session or patient encounter Do not use if a level II modifier can be used.
			76		Repeat Procedure by Same Physician		Use when a procedure is repeated: In a separate session On the same day By the same physician The procedure repeated must be the same procedure (same HCPCS code).
			77		Repeat Procedure by Another Physician		Use when a procedure is repeated: In a separate session On the same day By a different physician The procedure repeated must be the same procedure (same HCPCS code).
			58		A Staged or Related Procedure or Service by the Same Physician during the Postoperative Period of a previously performed procedure		Use when the performance of a procedure during the post-operative period was performed on the same day Planned prospectively at the time of the original procedure (staged) More extensive than the original procedure For therapy following a diagnostic surgical procedure Do not use to report the treatment of a problem that requires a return to the operating room (see modifier 78).
			78		Return to the Operating Room for a Related Procedure during the Postoperative Period of a previously performed procedure		Use to indicate that another procedure was performed during the postoperative period of the initial procedure on the same day Use if the subsequent procedure: Relates to the first procedure; and Requires the use of an operating room.
			79		Unrelated Procedure or Service by the Same Physician during a Postoperative Period		Use to indicate that a procedure performed: During the post-operative period on the same day By the same physician Is unrelated to the original procedure
			RT/LT		Right Side/Left Side		Use to identify procedures performed on the right/left side of a paired organ or central lateral anatomic site body. Use when the procedure is performed on only one side to identify the side operated upon Do not use if code indicates multiple occurrences. Do not use if the code indicates the procedure applies to different body sites or anatomic structures Do not use RT/LT if a more specific modifier is available. Do not use RT and LT when modifier 50 is appropriate.
			E1 – E4, FA – F9, TA – T9		Eyelids Fingers Toes		Use the most specific modifier available. If more than one level II modifier applies, repeat with each of the appropriate level II modifiers. Do not use if code indicates multiple occurrences. Do not use if the code indicates the procedure applies to different body parts.

Radiology			50		Bilateral Procedure		Use to report a procedure done bilaterally in same radiology session Use only for paired organs/body parts Do not use if code indicates multiple occurrences Do not use if the code indicates the procedure applies to different body parts Do not use if code description includes bilateral or unilateral
	70010-79999		52		Reduced Services		Use to report a service that was: Initiated Partially rcompleted No available HCPCS code describes the service performed Do not report a radiology procedure that was canceled.
		59		Distinct Procedural Service		Use for services not normally reported together. Use to indicate a service distinct or independent from other services performed on the same day. Use to represent (not ordinarily performed on the same day): Different procedure, Different site or organ system, Separate incision Separate injury (or area of injury in extensive injuries) Do not use if a level II modifier can be used.


			76		Repeat Procedure by Same Physician		Use when a service is repeated: In a separate session On the same day By the same physician The service repeated must be the same service (same HCPCS code).
			77		Repeat Procedure by Another Physician		Use when a service is repeated: In a separate session On the same day By a different physician The service repeated must be the same service (same HCPCS code).
			79		Unrelated Procedure or Service by the Same Physician during a Postoperative Period		Use to indicate that a service performed: During the post-operative period of a procedure performed earlier in the day By the same physician Is unrelated to the original procedure
			RT/LT		Right Side/Left Side		Use to identify services performed on the right/left side of a paired organ or central lateral anatomic site. Apply to codes that identify services that can be performed on paired organs, e.g., ears, lungs, ovaries. Use when the service is performed on only one side of a pair. Do not use if code indicates multiple occurrences. Do not use if the code indicates the procedure applies to different body parts. Do not use RT/LT if a more specific modifier is available.

Other Diagnostic	90700-99199		59		Distinct Procedural Service		Use for services not normally reported together. Use to indicate a service distinct or independent from other services performed on the same day. Use to represent (not ordinarily performed on the same day): Different procedure, Different site or organ system, Separate incision Separate injury (or area of injury in extensive injuries) Different session or patient encounter Do not use if a level II modifier can be used.
			76		Repeat Procedure by Same Physician		Use when a service is repeated: In a separate session On the same day By the same physician The service repeated must be the same service (same HCPCS code).
			77		Repeat Procedure by Another Physician		Use when a service is repeated: In a separate session On the same day By a different physician The service repeated must be the same service (same HCPCS code).
			79		Unrelated Procedure or Service by the Same Physician during a Postoperative Period		Use to indicate that a service/procedure performed earlier in the day During the post-operative period By the same physician Is unrelated to the original procedure
			RT/LT		Right Side/Left Side		Use to identify services performed on the right/left side of a paired organ or centra lateral anatomic site Apply to codes that identify services that can be performed on paired organs, e.g., ears, lungs, ovaries. Use when the service is performed on only one sideof a paired organ or centra lateral anatomic site. Do not use if code indicates multiple occurrences. Do not use if the code indicates the procedure applies to different body parts. Do not use RT/LT if a more specific modifier is available.
	92980-92982, 92995, 92996		LC LD RC		Left circumflex coronary artery Left anterior descending coronary artery Right coronary artery		Use to identify vessel upon which the procedure was performed. If more than one level II modifier applies repeat the HCPC code in another line with the level II modifier

Evaluation and Management	99201-99499		25		Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure of Other Service		Use to indicate that the patient required a significant, separately identifiable E & M service on the same day a procedure was performed. Use for an E & M service that: Is beyond the usual pre-operative care associated with the procedure A separate history was taken a separate physical performed, and medical separate decision made

Condition Code G0 (zero)

Hospitals must report condition code G0 in form locator 24-30 when distinct and independent visits on the same day in the same revenue center can be reported on separate claims with condition code G0 on the second and any subsequent claims.

EXAMPLE: A beneficiary went to the emergency room twice (morning and afternoon) on the same day for chest pain. This situation would apply if the beneficiary came back for a different or same reason.

Proper reporting of condition code G0 allows for payment under OPPS. If condition code G0 is not present and service units are greater than 1, the system will reject multiple medical visits on the same day with the same revenue code.

Billing Example 1 (one claim submitted)

One claim

Condition code G0 is one the claim