Below are the questions received during our recent webinar, Surgical Modifiers, originally presented on September 7, 2021. These questions have been answered by the webinar presenter, Paul Spencer, CPC, COC
Where Neurosurgery use unlisted CPT 64999 and ENT had to use to 31299 where ENT made the approach and Neurosurgeon resected the tumor or procedure. We can't use 62 due to different CPT but we have seen denials so we do note "Procedure comments" to indicate co-surgery. Any feedback
That is about the best that you can do. Because so many procedures fall under "unlisted" that you have to have documentation that drives the reimbursement. In these cases, be as specific as possible in the operative report.
can you address modifier 24? Can you site your reference for Modifier 52 & 53 criteria?
Modifier 24 is used on an E/M code for a service in the postoperative period for a distinct service unrelated to the surgery. Remember that based on AMA CPT global surgery rules, "typical postoperative care" is included in the global package. If the care is atypical, use the 24. Basically, 52 and 53 was based on AMA CPT rules. Your MAC rules may vary.
Can you use modifier XU on 76000 during SX instead of modifier 59?
It is not recommended, but I would have to know the full surgical procedure to comment further. Typically, the X modifiers are for surgical CPT codes
57 modifier: Can this be used on an e/m code with non manipulative fracture care codes such as closed tx without manipulation of a distal radius fracture 25600? 76/77 modifier: does this apply to the same day or does it apply anytime during the global period for that same physician/qhp? 58/78 modifier- which modifier is used for complications arising from a previous surgery still in the global period. Ex…wrist fracture treated with no manipulative fracture care code has displaced more now needing ORIF or knee requires manipulation for arthrofibrosis that is still during the global for a total knee.
In order, the urgent care center is billing this incorrectly and non-compliantly. By billing E/M codes, it compunds the problem, rather than fixing it. Usually, fracture cases see orthopedic physicians on an as-needed basis, so most of the patients are new. a little know NCCI tidbit is that new patient E/M services often don't need either a 25 or 57 if a procedure is performed the same day. In a case such as the one you mentioned, I have never seen the 57 utilized. Modifiers 76 and 77 are for repeat procedures on the same day. Your final scenarios are covered by modifier 78, as the return to surgery was unplanned.
or could we use the 78 modifier instead of the 58?
The key here is whether there was planning to take the patient back to surgery based on the margins. If there was a tentative plan to return to surgery, use modifier 58. Otherwise, use modifier 78.
Is modifier 57 appropriate for an ED physician as well, when we admit them to the hospital knowing surgery is scheduled?
The 57 is for use by the surgeon
re: hospital admissions - If a patient falls postoperatively, loosening the hardware from the surgery, is an E and M billable since "falls' are not part of the global package?
This would be considered atypical postoperative care. Bill the E/M with modifier 24
Scenario--pt has back surgery, then in the global period they are in a auto accident and has to have the same back surgery performed again...which modifier you you recommend?
I would use the 78 modifier if it is the same physician, as this was an unplanned return to the OR.
When assistant surgeon is a resident, must the surgeon state why assistant surgeon is required?
Even if you're not billing for the resident, it is best to be in the habit of explaining that there is a qualified resident on the case, and for which parts of the procedure the resident was involved.
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