Modifiers: It’s all about the money! – Part 2

In part 1 of this modifier series we identified and discussed the largest category—Global Package Modifiers, and the following modifier categories: GP, BUN, E/M only, #, Anes, Lab, and OTH. In part 2, we will explore the other categories of modifiers starting with the “BUN” grouping. 

The following are the modifiers that relate to the bundling of CPT codes or related CCI edits:

There are several situations where one CPT code is bundled into another or mutually exclusive. For example it is an error to charge and office visit code (i.e.. 99212) with a procedure code if the reason for the visit was the procedure only. It is understood that there is an inherent evaluation and management component to doing every procedure and a separate EM should not be billed. There are, of course, circumstances where a truly separate and significant EM was performed in addition to the procedure. Perhaps the patient came in for an office visit but on the way in got a laceration to their arm that needed stitches. The physician performed a laceration repair and also did the scheduled office visit. In this case, modifier 25 would be appended to the EM code to indicate it was not part of the laceration repair. In these situations, it is a good documentation practice to keep the procedure note separate from the EM note so there can be no confusion that they were separate services. This is especially helpful if documentation is requested to support the claim.

Modifier 26 is used when a CPT code such as a radiology code has both a technical and professional component. Medicare provides, in the physician fee schedule database, a column that indicates if codes are considered global and if so what percent they pay for the technical and what percent they pay for the professional. So if a patient has had an x-ray and now a radiologist is doing the reading and interpretation only then modifier 26 would need to be appended to indicate they did not do the technical piece. Hospitals that employee radiologist will bill the technical piece on the 1450 form and bill the professional piece on a 1500 form with modifier 16 appended. Freestanding radiology centers that employ the radiologists will often just bill the radiology code with no modifiers indicating the provided both the technical and professional piece and deserve to get paid the full amount.

The Correct Coding Initative provides edits that indicate when one code is bundled into another or mutually exclusive. For example, a laparatomy is bundled into an oophorectomy and the two should not be billed together; however, some code pairs have a notation that indicates that under some circumstances both codes could be coded together. A patient could have had an oophorectomy in the morning but then a complication arose in the afternoon and an exploratory laparotomy was performed. In this case it would be appropriate to bill the laparotomy with the oophorectomy and would take modifier 59 to indicate that it was indeed distinct from the oophorectomy.

Another family of modifiers is the EM only grouping all of which were discussed on the Global Package or Bundling family of modifiers. The key with these is to remember they only get appended to EM codes.

Stay tuned as the next part of this series will discuss the remaining modifier families.

Written by Laureen Jandroep, CPC