Often times, chronic pain can lead to a patient needing a surgical procedure. These procedures usually come with a 0-, 10- or 90-day global period. A global procedure is a period in which the provider cannot bill for services. Global surgical packages are procedures and services performed during the preoperative period, during the procedure, and post procedure. In this article we will discuss:
- Understanding global procedures
- Modifier usage and descriptions
- Review of NCCI Edits
- What is an LCD and NCD and how does it affect coding
- Tips on coding
Understanding Global Procedures
A global procedure is a period in which the provider cannot bill for services.
Global surgical packages are procedures and services performed during the preoperative period, during the procedure, and post procedure.
Global Surgery Indicators
Medicare has created payment rules for global procedures called global indicators, and most insurances follow suit. Figuring out the global days of a procedure can be challenging. But there are some things to note. First, it is important to know the surgical packages based on the number of post procedural days. The payment rules for global surgical packages apply to procedure codes with global surgery indicators of 000, 010, 090 and sometimes YYY. A description of the global surgery indicators are as follows:
- Codes with “000” are for some minor surgical procedures (zero-day postoperative period).
- Codes with “010” are other minor procedures (10-day postoperative period).
- Codes with “090” are major surgeries (90-day postoperative period).
- Codes with “YYY” are contractor-priced codes, for which contractors determine the global period. Not all contractor-priced codes have a “YYY” global surgical indicator.
Details on specific codes can be located on the Medicare fee schedule
Modifier Usage and Descriptions
What are modifiers? Modifiers provide additional information about the medical procedure, service, or supply involved without changing the meaning of the code. Modifiers are arranged by pricing, payment, and location.
For example, a few are TC and 26 which are pricing modifiers 50 and 59 are payment modifiers, and RT and LT are examples of location modifiers. Knowledge of modifier usage will be important when coding for chronic care. Some procedural coding will have specific guidelines on when to use a particular modifier, or when multiple modifiers can be used. Modifier 50 is an example of this.
Modifier 50 (Bilateral Coding)
Modifier 50 is used to show the procedure was done on both sides. Medicare has established bilateral surgery indicators that detail how modifier 50 should be used. The indicators can be found on the physician fee schedule. Below are the indicators for bilateral coding.
Bilateral Indicators
- Indicator 0: Bilateral surgery rules do not apply. Do not use modifier 50
- Example: Office or other outpatient visit for the evaluation and management of an established patient (99214) Modifier 50 is not allowed
- Indicator 1: Bilateral surgery rules apply. Use of modifier 50 would be appropriate if performed bilaterally with 1 unit. Medicare may reimburse at 150 percent.
- Example: Impaction removal on both ears (69210)
- Indicator 2: Bilateral surgery rules do not apply. This is priced as bilateral. Codes with this indicator include bilateral in the code description procedures. Modifier 50 should not be added.
- Example: Osteotomy, pelvis, bilateral
- Indicator 3: Bilateral surgery rules are not subject to payment rules for other bilateral procedures. If submitted with modifier 50 or LT or RT with 2 units, Medicare may reimburse at 100 percent of the allowed amount. This indicator is frequently used on radiology codes.
- Example: Radiologic examination, wrist; 2 views (73100)
- Indicator 9: Bilateral surgery concept does not apply
Inappropriate use of Modifier 50
- Inappropriate to apply to a “bilateral description” code.
- Do not append to procedures for midline organs such as the bladder, uterus, esophagus, or nasal septum.
- Inappropriate to report when performed on different areas of same side of body.
- Modifier 50 cannot be appended when bilateral indicators are 0, 2, 3 or 9.
Modifier LT and RT
Modifiers LT and RTs guidelines are not as detailed as modifier 50. These are used to identify which structure was operated on. They are descriptive modifiers and unlike modifier 50, they do not directly affect payment. But they provide further details that contribute to reimbursement.
When to Use Modifier LT or RT
One example of how modifiers LT or RT are used would be; adding either LT or RT to procedure that is performed unilaterally. This is done to describe the side the procedure was performed on for a unilateral code. An example of this would be 27560 -RT (closed treatment of patellar dislocation. Modifier RT would be added if the right side of the procedure were performed.
In some cases, some payers will require only RT and LT to be appended on two separate lines in place of modifier 50. It is important to check with payers before selecting the appropriate modifier. Each payer may have their own requirements of how they want the modifier added and the details on the service line and units.
Modifier 59
Modifier 59 is also commonly used and in many instances used inappropriately. This represents a different procedure or surgery not ordinarily performed on the same day by the same physician. If there is another appropriate modifier, 59 should not be appended. This modifier is used many times unnecessarily for cases that are not separate and should not be reimbursed separately.
Modifier 59 Subsets
Since modifier 59 applies to a variety of circumstances and has been misused so often subsets were established by Medicare. These subsets are to be used for more specificity, and many more insurances have adopted this model as well.
The subsets are as follows:
XE- separate encounter which is a service that is distinct due to occurring during a separate encounter
XS- distinct service that is performed on a separate organ or structure
XP- a service performed by a different practitioner
XU-use of a service that is distinct because it does not overlap (sometimes used in place of modifier 59)
Inappropriate use of Modifier 59
- Do not use modifiers 59 or XU just because the code descriptors of the 2 codes are different.
- Do not report the 2 codes together if they are performed at the same anatomic site and same patient encounter, because they are not considered “separate and distinct.” Do not use modifiers 59 or XU to bypass a PTP edit based on the 2 codes being “different procedures.”
Appropriate use of Modifier 59
When two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service, you may use modifiers 59, XE, or XS to show that they are different procedures on that date of service.
Evaluation and Management Modifiers
There are some modifiers used only on evaluation and management codes. Some common modifiers are modifiers 24 and 25. Modifier 24 is for an unrelated evaluation and management during post-op. Modifier 25 is for a separate identifiable E/M service.
Another common modifier is 57. This is used when the visit results in a decision to perform surgery. For instance, a patient might be seen in the clinic for a chronic condition. During the visit, if the chronic condition turns severely acute the provider may decide to perform surgery. In this scenario, modifier 57 could be appended. This should be added within 24-48 hours.
Consequences of Using Modifiers Incorrectly
Correct coding is imperative. Adding modifiers without the proper documentation for the sole purpose of higher reimbursement could result in disciplinary action. In some cases, this can trigger an audit. If the determination is intentional misuse, there could be serious fines. These fines can be thousands of dollars for each modifier used incorrectly.
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What are NCCI (National Correct Coding Initiative Edits)
NCCI edits were created by Medicare to prevent inappropriate payment of services. National Correct Coding Initiative Edits are coding combinations that should not be reported together and considered mutually exclusive. There are several types of edits. One is a PTP (procedure to procedure) edit. These edits consist of two columns, column 1 and column 2. Reimbursement will only be given for column 1 code.
In some instances, a modifier can be used to specify two distinct services. In this case, a modifier can be used to distinguish a separate procedure was performed. An example of this would be coding 29827 and 29820, a modifier would be able to bypass this edit if documentation supports the use of it. In other instances, there are no modifiers that can bypass the edit.
MUE Edits
Another type of edit is an MUE edit. These edits occur when claims have too many of the same services for the same date. Not all CPT’s have an MUE limit.
What are NCDs and LCDs
Medicare uses coverage policies to determine which services should be paid or not. In some instances, Medicare develops these by reviewing evidence-based research. These are called LCDs and NCDs.
NCD (national coverage determination) is decided based on clinical decisions, treatments, and other factors. Once Medicare has established an NCD, all MACs (Medicare Administrative Contractor) must comply. LCD is a local coverage determination. LCDs are specific to the MAC’s jurisdiction. For example, a service that is covered in Chicago may be different from what is covered in Florida. A search for both LCD’s and NCDs can be found on the Medicare coverage database.
Tips on Coding
There are a few tips for coding to note. One is to stay up to date on coding guidelines and updates. One way to do this would be to attend local or online seminar training when available. AHIMA and/or AAPC provide training for multiple topics that are constantly being updated. This will help keep up to date with current guidelines as well as upcoming changes. Reading guidelines will also help when there are codes that require additional coding.
Another tip would be to pay attention to the provider’s documentation. This will be a guide for selecting codes accurately. Many times, there will be documentation that is unclear or missing, and in some instances make coding impossible. An example of this would be incomplete medical decision making. For issues like this it would be appropriate to query the provider to review and update if necessary. Capturing all the codes for an encounter is also important as this will maximize reimbursement.
Conclusion
As you can see, medical coding and billing for global procedures and modifier usage are very complex with many guidelines listed in the AMA CPT codebook.
For assistance with this process, please do not hesitate to reach out to us directly. At Neolytix, we are always ready to assist your practice with medical billing, coding, and revenue cycle management.
Our medical billing services are 100% HIPAA-compliant and provided by a certified team of professionals. Likewise, our medical credentialing services are fast, efficient, and organized according to rigorous workflow management procedures.
