Modifiers are two-digit codes appended to procedure codes and/or HCPCS codes, to provide additional information about the billed procedure. In some cases, the addition of a modifier may directly affect payment.
Modifiers can not only cause denials in reimbursement, but can be
considered fraudulent if billed incorrectly. It is imperative that you
understand the description of modifiers and when and how to use
correctly.
Modifier -54: surgical care only – Modifier -54 is used when a
physician performs a surgical procedure and another physician provides
the pre-operative and post-operative management services of the
patient. Modifier -54 is appended to the surgical code. Remember that
all major surgeries have global days and you need to verify what other
services are bundled into the surgery.
Example: A patient has a mastectomy and begins chemotherapy for 12
weeks. Modifier -54 would be appended to the mastectomy code.
Modifier -55: post-operative care only – Modifier -55 is used when
one physician does the surgery and another physician provides postoperative
care only. In order to bill for post-operative care without
performing or assisting with the surgery, append modifier -55 to the
procedure code. Post-operative care begins the day after the surgery. If
the patient is diagnosed with another problem during the post-operative
period you would bill it separately with a different diagnosis code.
Example: if a patient has surgery performed by a neurosurgeon and the
follow-up care if performed by the neurologist you would append
modifier -55 to codes billed by the neurologist. Modifier may have an
effect on payment.
A complete list of all Medicare approved modifiers can be found at the
CMS website. www.cms.hhs.gov
If you need any additional information on this article or Coding & Compliance services please contact Cindy Tipton at Cindy_Tipton@MED3000.com
For a printable version, click: CCNewsletterMarch2008
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