Section 2 CONVERSION FACTOR CPT MODIFIERS CCI EDITS Modified For 02-21-14 010514 9:15 to 10:00 AM 44 Privileged and Confidential Work Product – Subject.

Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

Section 2

CONVERSION FACTOR CPT MODIFIERSCCI EDITS

Modified For 02-21-14

0105149:15 to 10:00 AM44


Medicare participating fee schedulesNIB

Fee schedules vary considerably among all the carriers, therefore we only include a few limited fee examples with this work book


Fee Schedule Background

• The current Physicians Fee Schedule (PFS) system started in 1992.

• PFS pays for covered physicians services under Medicare part B.

• Relative Value Units (RVU) are assigned to more than 7000 AMA Current Procedural Terminology (CPT) described services.

• The RVU covers physician work, overhead practice expense, and malpractice.

• The RVU times Geographic Practice Cost Index, (GPCI) times CF equals physician payment dollars.


The Medicare conversion factor has been calculated each year based on the Gross Domestic

Product Index using the Sustainable Growth Rate formula.

Medicare Conversion Factor 5


• The National Conversion Factor is that number assigned by CMS which, when multiplied by the RVU, results in the dollar value of the procedure as allowed by Medicare

EXAMPLE: If the professional RVU is 2.50 And the technical RVU is 5.25 Then the global RVU is 2.50 + 5.25 = 7.75

If the current conversion factor is $34.02, therefore;

7.75 X $34.02 = $263.68 global payment

National Conversion Factor 5


2008-2014 Conversion Factor

• 2008 it was increased to $38.0870.• 2009 The CF dropped to $36.0666• 2010, To prevent the scheduled -20% reduction, the

CF was temporarily set at $36.8729• 2011, set at $33.9764, the CF had not been this low

since 1997!• 2012 set at $34.0376.• 2013 set at $34.0230.• 03-01-13 -2% reduction due to sequestration.• 2014 Frozen at $34.0230.

5

14/90


The AMA’s Current Procedural Terminology (CPT) has been published since 1966, starting just 2 years after Medicare became law .

The standardization of nomenclature by CPT has unified professional and

hospital billing throughout the health care industry.

CPT and ICD9-CM NIB


• Seventy nine specific radiation oncology codes exist

• Of these codes Hospitals or centers for radiation therapy may report thirty one technical-only codes

• The radiation oncologist has access to all 99000 series E /M Codes

• The radiation oncologist may also utilize other specific codes from other specialties

Radiation Oncology CPT CodesSection 2, pages 1-4

6/90


Categories of CPT-4 codes

Category I codes. These are currently active common use codes, 5 digit #, (77334)

Category II codes. These codes are supplemental tracking codes, used for performance measures, an alpha and 4 digits, (G0243)

Category III codes. These codes are for emerging technologies, and are used for tracking usage, 4 digits and an alpha ( 0083T)

2


The Index of CPT Procedures is covered on pages 2.01 to 2.04.The CPT codes are followed by the CPT descriptors and the

section of the User’s Guide where they may be found.

Covered by pages 2.01-2.04


Modifiers for use inRadiation Oncology

Covered by pages 2.07-2.17


One of the most misunderstood, and consequently under-utilized sections of CPT, is the portion dealing with modifiers.

These are some of the most common modifiers that are likely to be useful in radiation oncology.

Modifiers 6


Modifiers Selected ByBMSi Seminars

As Most Applicable ToRadiation Oncology Billing

7


-22 Increased Procedural ServiceThis modifier is used when the work required is “substantially” greater than the services usually required for the listed procedure. In radiation oncology, -22 would be appropriate for attaching to the more complex of the various codes such as: 77263-22, 77290-22 , or 77295-22, 77334-22, 77427, or 77431-22, and 77470-22. Detailed, written explanation and documentation of the reason for the extra work is required.

-22 ModifierCovered by page 8


9

Modifier -22


-25 Significant separately identifiable Evaluation & Management Service by the same physician on the day of a procedure

The physician needs to indicate that on the day a procedure or service was performed, the patient’s condition required a significant separately identifiable E&M service .

This circumstance may be reported by adding the modifier –25 to the appropriate level of E&M service.

-25 Modifier Covered by page 9


An example is a fiberoptic endoscopy (31575) done on the day of a follow-up exam. You should bill this as:

99213-25 Follow-up Visit31575 endoscopic examination of

the larynx.

-25 Modifier

Covered by page 9


Another example was the use of any up front 77000 code done on the day of the initial evaluation, 99201-99205, 99211-99215, 99221-99223, 99231-99233. You should bill this as:

99203-25 Initial office visit77263 Complex treatment planning

This was a ruling (01-01-10) to allow “set and treat”, or just getting started on the initial set up situations in radiation therapy

-25 Modifier 9


– 25 may not work

• Starting in 2013 many of the carriers have started to bundle all procedures done on the day of an initial evaluation or follow-up examination into the value of the E/M procedure.

• See, set, start, and treat may no longer be possible without considerable loss of revenue. THIS USE MAY NO LONGER BE AVAILABLE. CHECK YOUR 2013 LCD

Section 5, page 5


-26 Professional ComponentWhen the physician component is reported separately from the technical service , the service must be identified by adding the Modifier -26 to the procedure code.

This will apply to almost all of the physician's billing in a hospital setting. The hospital will be billing the technical component to the APC utilizing the same CPT codes but without the -26 modifier.



WHY NO -26 NEEDED?

• 77261-77263, 77427, 77431, 77432, 77435, and all 99XXX codes are professional only, so no professional modifier needed.

• 77336, 77370, 77371, 77372, 77373, 77401-77418, 77422, 77423, 77520-77525, are all technical only codes, so no professional component available.

• All the rest have both components, so the -26 is needed to indicate professional only billing


-52 Reduced Services

This code is used to downgrade the charge for a procedure that is being performed at less than the usual intensity.

Modifier -52 is not recommended for use in radiation therapy except when a procedure has been terminated early and is incomplete.



-58 modifier

• -58, staged or related procedure or service by the same physician during the post op period

• Most commonly used for multiple HDR procedures on same date of service

Page 12


-59 Modifier

-59, Distinct Procedural Service.Used to indicate that a procedure or service was distinct

from other services performed on the same day

When multiple procedures are performed on the same date, and a CCI edit has a ”1”, this modifier may be used to identify the secondary or lesser procedures that may be billed utilizing the same original CPT codes.

May be used with E/M code and other procedureMay be used for repeat HDR procedures.May be required for BID treatment delivery codes

Covered by page 12


-59 Modifier

• Use the 59 modifier only when you are seeking to unbundle a NCCI edit, and no other modifier works.

• When repeating the same service on the same patient, on the same date, use modifier 76 after the 1st procedure.


-76 Modifier• -76, Repeat procedure by the same physician on the

same date of service

When multiple procedures are performed on the same date, and a CCI edit has a ”1”, this modifier may be used to identify the secondary or lesser procedures that may be billed utilizing the same original CPT codes.

• This modifier may be required by your carrier for services such as 77300, 77334, 77290 and 77280 which may be multiple on the same date

Page 13


The -GC modifier is used when services are performed in part by a resident and under the direction of a teaching physician.

The -GE modifier is used when a service is performed by a resident without the presence of a teaching physician.

These modifiers should accompany each code that is reported.

If a resident is not present when the procedure is done, these modifiers would not be used.

-GC – GE ModifiersCovered by page 14


Proper notation of involvement of the resident in the direct care of a patient

15


When any modifier is being used, with the exception of -26, GC or GE modifiers, your claim may subject to Carrier review.

When appealing the claim, it is strongly recommended that a detailed report be attached to the bill explaining the necessity for the additional procedure.

Detailed Report Needed15

36/90


Physician Cross CoverageA series of examples are in your book related to two Radiation Oncology Physicians,DR GREENDR BROWNand the complex set of rules related to how physicians may cross cover for each other under various scenarios.

15


-Q5 MODIFIER

• The –Q5 is used for reciprocal billing between two unrelated practices.

• -Q5 Services provided by a substitute physician.

• Reciprocal billing is for out of the department, time off, weekend or other on call between two unrelated practices of the same or similar specialties.

• If Dr Green’s patients are seen by Dr Brown, those cases will be billed by Dr Green using the –Q5 modifier, very similar to a locums arrangement, but only a letter of understanding is required.

15/17


-Q6 MODIFIER

• The -Q6 modifier is used to indicate the services of a locum tenens physician

• The covered physician must be absent from the practice

• A written contract is required.• Service is limited to 60 continuous days

Covered by pages 16


The requirements for submission of claims under locum tenens billingare the same as regular claims submission.The locums’ physician is paid a contract value for services performed, or

per diemAll codes requiring the Q-5 or Q-6 modifier are submitted under the NPI of the covered physician

17


LOCUMS SIGNATURE REQUIRED WITH REGULAR ATTENDING PHYSICIAN

SIGNATURE

18


NATIONAL CORRECT CODING INITIATIVE EDITS (CCI)

• This is Medicare's editing software that bundles code combinations to limit payment of these codes on the same date of service

Covered by pages 19-22

46/90


The rules of CCI edits are supposed to apply only to services performed on the same date for the same patient by the same physician

If an edit exists , and the proper modifier is not used on one of the codes, the claim will be denied payment

19


Code Pair Combinations• Mutually exclusive code pair edits• Comprehensive component code pair edits• Three CCI indicators are used “0” “1” “9”

20


“0” IndicatorA “0” marked on a code edit signifies that these code combinations should not be billed together and that only one will be paid regardless of any circumstance or modifier.

An example is 77301 vs. 77263”0”.

20


21


“1” indicator codes could be billed on the same date of service if a modifier is appropriately used.

The most common modifiers are a -59 (distinct procedural service), or -76 (repeat procedure by same physician) No modifier is used on the first report, but used on all subsequent reports (77334, 77334-76)

19


“9” IndicatorThe modifier “9” indicator typically means that the mutually exclusive edits, which previously applied, have been deleted.

An example of codes that were once mutually exclusive is:

77301 vs. 77300”9” effective 4/2001

19


20


MEDICALLY UNBELIVEABLE MEDICALLY (UNLIKELY) EDITS

• MUE’s apply a unit of service limit to virtually every CPT code

• Similar to CCI, but originally no modifier override• May now try -55, -76, -77, -59, but generally is still

denied. Modifier GD wont work.• Exceed a MUE, and the service is denied• The purpose of MUE is to prevent “ billing errors

from incorrect entry or misunderstanding interpretation of codes”

21


Comments by D. Scott Simmons,

HOW TO USE NCCI ON-LINE

Teaches you how to use the government web site for old, current, and new rules and regulations.

See the last section of the book

22-23


PRINCIPLES OF BILLING, CODING AND COMPLIANCE

IN RADIATION ONCOLOGY

BMSi 2014End Introductory Section

Section 2 CONVERSION FACTOR CPT MODIFIERS CCI EDITS Modified For 02-21-14 010514 9:15 to 10:00 AM 44 Privileged and Confidential Work Product – Subject.

Documents

codes category

specific codes

codes hospitals

medicare conversion

physician work

current conversion factor

work book

supplemental tracking