Hello, everyone. This is Mary Gregory. Welcome to May. This, you know, the most important date we have in May is Mother’s Day, so I want to say Happy Mother’s Day to all you mothers out there. and we want to honor our mother, you know. Don’t think about the fact, you might be thinking, well, I didn’t have the best mother in the world.
Well, you know, guess what? She was human. Happy Mother’s Day. She made mistakes. We all do. We’re not perfect. So, just love your mom and if you don’t have a great relationship with your mom, work on it. forgive and forget. It’s a good thing. And then after Mother’s Day, we have Father’s Day, which is June. So, I’ll talk about fathers here.
Fathers are very, very important, in our lives. And then we have, what, July the 4th. And you might say, Mary, what are you talking about? I am talking about the fact that you may want to get a certification and all these things are going to interfere with your time. So, you’re going to have to find time to study.
You’re going to have to find time to prepare. Just take a class here or there. sometimes we want to overdo things. We want to do it all in a moment’s notice, sort of. No, sometimes you’re just going to have to do a one, they say, how do you eat an elephant? One bite at a time. And that’s the way you might want to do your certification.
So if you’re thinking about getting your CCS, take a pack, take a class on, inpatient coding, how to assign the principal diagnosis, how to determine when you’re going to code secondary diagnosis. So, If you want to do outpatient, then you’re going to go look at CPT and you’re going to say, okay, I’m going to take a class on CPT or I’m going to study CPT.
Maybe you already in coding, but you want to get an outpatient credential. Then study some CPT because maybe you spend all your time doing inpatient and we all know with inpatient, we use a different procedure book. We use a book called PCS. so just remember, you’re going to have to find the time because for me, Once July the 4th passed, you’re on vacation, then in August, children are going back to school.
So it’s always going to be something that could take your time away. So you’re gonna have to find that time. All righty, that’s gonna lead us into what we want to talk about the first part of May. We may have another presentation in May. We may have many, who knows. But today, we’re going to be talking about the This is just a very brief review on the fundamentals of modifiers.
We’re just going to do this fundamental. You know, when you take the, I think, I know the CCS and I know the CPC. Yeah. I don’t think they give you modifiers on the CRC. They could, They just give you very basic things you should know about a modifier. They’re not going to give you the most complicated case to code.
Where you’re going to have to apply all of these different types or really think really hard about these modifiers, which one is appropriate. They’re going to give you very, very basic things. All these tests are testing your basic skills. They’re not giving you the hardest thing out there. They just want to know, do you have the basics?
And you know, I’ve done this another day and I’m probably going to start saying this more. People come to you and they say, teach me how to pass the test. No, I’m going to teach you how to code. Because if you know how to code, you’re going to pass the test. But if you just learn how to pass the test, you don’t know how to code.
And you’re not going to be able to keep a job. Well, I probably shouldn’t say that, people don’t like that kind of stuff. But, I said it, so what? Okay, let’s get into the fundamentals of coding. The fundamentals of modifiers. Why modifiers? Why do you even want to use a modifier? First of all, I use modifiers to tell a story.
I am trying to tell a story so I can get paid and not only so that my hospital, if I’m working for a hospital or physician, who am I working for? I want to tell the best story, so not only will they get paid, but they’ll get to keep their money. See, now it’s not just enough to get the money, now you got to keep the money.
So remember, when you’re doing modifiers, you’re telling a story. What kind of stories do I want to tell? Sometime my service or procedure may have a personal, professional or technical component. I may need a modifier 26 if it’s personal, professional, excuse me, or TC if it’s, a technical part.
Cause sometimes somebody can own the equipment and so you, you’ll have to know when I need to do the pers, professional and the technical. I’m telling that story. Sometime. It’s more than one physician have to work on a patient. So I’m going to have to tell that story. Is it an assistant surgeon? Is it a resident?
Is it a co surgeon? So we can have modifiers. Once again, to help the insurance company to know that there were multiple surgeons involved. And sometimes that’s very important because they’re going to pay you for that assistant or surgeon. And so that way you can pay the guy that assists you, or the gal, or the girl that assists you.
Sometime we have to show that a service was increased or reduced. Did it cause more work now when you use modifier 22? I believe it is. They, that’s, that’s the modifier. That’s kind of pretty much abuse because everybody feel like they’ve done a lot of extra work. Well, maybe not, but it is, it is a way to show when it is appropriate that you did do much more work.
And of course, did you have to reduce the procedure in a certain way? maybe you only performed part of the procedure. Did, did you have to have another procedure that you normally would not have in this procedure that they would tell you that you cannot build together, but in this case it’s appropriate to build the two.
So remember, the fundamentals of modifiers is that you’re trying to tell a story, so that you’ll get paid and you’ll keep your money. The other fundamental of modifiers, there are two types of modifiers, there’s what we call level one modifiers, which are your CPT modifiers, and they are always numerical, and then you have your level two modifiers, which is your HPT’s modifier, and they are always alphanumeric.
So you want to remember that. The other thing in dealing with modifiers is back in, I, I think late 90s or early 2000s when CMS came out with the NCCI edits, National Correct Coding Initiative edits. Why did they have to bring these edits out? Well, because they felt like there was a lot of misuse, abuse, and sometimes fraud involved in modifiers.
And they said we gotta fix this. Now personally, they have watered these CCI edits down so much that they’re not as strong as they used to be. that’s just my own personal opinion. These models, when they first came out with the CCI edits, we took the N off and just said CCI edits. Correct Coding Initiative.
When they first came out, it was a lot of things you could not build together. And so, but they have watered them down because people went to them and said well you know we always have this exception. And because you always have an exception, they decided well maybe we should allow modifiers. Maybe we should not allow them.
So they allow modifiers in a lot of cases where sometimes I’m like hmm, I wonder. So anyway, your modifiers are used on what they have what they call column 1 and column 2 codes. And they call them PTP, Paul, Tom, and Peter. And so, they stand for Procedure to Procedure. And so, there are certain procedures that they said, Look, you cannot use a modifier to bypass.
Zero, if you have a zero, now your coding software will not say zero, it will just say you cannot bypass this edit. But there’s a zero in place there when they put that program in your system. And that zero says the modifier cannot be used to bypass the edit. The one says that A modifier is allowed to bypass the edit, but only if you have the proper documentation to support that that should be bypassed.
And then nine means it’s not applicable. They don’t even have edits on it. For instance, if you went to CPT book and went to code 24310, and you, that was, that’s a column one code. Your column two code is 0213. T as in Tongue, they will allow a modifier with that, see. So if I had those two things together, if I’m going to use, if I’m going to bypass it, my documentation better support the bypassing.
And you have insurance companies that look at this. Just because you bypassed. A edit doesn’t necessarily mean you’re going to get paid all the time. They may disagree with you bypassing the edit. Maybe your documentation is not strong enough to support that it was something that should be bypassed. And you have to be very careful in looking at that.
Once again, modifiers should only be appended to your CPT or HCPCS level 2 code if your clinical circumstance justifies the use of the modifier. Your documentation has to justify the use of that modifier. And you should never ever use a modifier just to bypass an edit. And not everything need a modifier.
There are some things that are just common sense, that you don’t need a modifier, even though you may get an edit. Say for instance, if I have a patient that have an EGD and a colonoscopy, both of those have separate procedure in parentheses, if you looked at it in CPT book, where my edit will say these are not normally, they’re separate procedures.
But guess what? They’re not related. One is top, one is bottom. I don’t really need a modifier. See, because it’s just common sense. The EGD is not performed the same way a colonoscopy is. And so I’m not going to be using, I don’t, I don’t call myself a modifier queen. There’s some people out there that just put a modifier on everything.
And you don’t need a modifier on everything. You just need modifiers when it is appropriate to do so. When you’re trying to tell that story. When you’re trying to tell a story. You know, if someone has a bilateral procedure, a left and a right, then guess what? If my CPT code doesn’t say unilateral slash bilateral, I am going to code it twice, or I’m going to code it one time and put modifier 50 on it.
And I, excuse me, I said I may code it twice, but that simply means there are some insurance companies that say, look, I don’t want 50. I want you to code it twice. I want you to put LT for left on one and RT for right on the other one. And so sometimes we have to do it the way the insurance company want us to do it as long as, as long as it’s appropriate.
And there may be times I’m going to have multiple procedures and I want to tell them I got multiple procedures going on. But be careful with your multiple procedures. Always put your highest paying procedure first. Medicare will fix it for you. I’m not so sure everybody else will. So remember you’re telling a story.
So your modifier is going to give information, or that modifier is going to affect your money. It’s going to affect pricing. So always think about, and pricing modifiers go first. And, So, information modifier, I was trying to think the other day, information modifier, let’s maybe, hmm, I didn’t bring my CPT book in, is it, what, 27 maybe?
Nope, 27 is multiple ED visits, or multiple visits on the same day. We generally use those, in the hospital setting with a Condition Code, G. O. But yeah, some, some modifiers just give information like a left or right. It might just be giving information. You know, someone had a cataract performed. They want to know if it was left or right.
Now, it’s not going to affect payment, but guess what? And sometimes this happens, this is why we have to be careful. If someone come in, in 2020, 2020, And you said they had a right cataract, but they really had left. And then they come in in 2021 and have a left cataract. But, but you, okay, let’s see in 2020 you put LT on the right one.
Okay. That was the wrong modifier. When they came in to truly get the left one done, the LT, Guess what? That Medicare Common Working File will not pay for it because you know what they said? Well, you had the left one done in 2020 and the patient is like, no, I had the right one done in 2020. I’m having the left one done in 2021.
So now we got a mess on our hands and trying to get this straightened out. So these modifiers that give information left or right. Upper eyebrow, lower eyebrow, right toe, left toe, they are very, very important because Medicare keep record of that and, you know, if you say you amputated somebody’s right leg in 2015 and then you’re going to tell them you amputated the right leg again in 2018, nah, you don’t have one right leg, see.
So that’s how informational modifiers are used. And price and modifier, you get additional money. You get additional money when you put a 50 on a, on a CPT code. now, when that CPT code says, right, says unilateral or bilateral, guess what they do? They pay you 150 percent every time you do that procedure, whether you do it bilateral or not.
That’s, that’s their way of equaling things out. So let’s kind of just review, because this is not a very long, presentation. You’re going to use modifiers to give information about an anatomical site. You’re going to use a modifier to eliminate the appearance of duplicate building. You can use a modifier to eliminate the appearance of unbundling.
Because remember, you’re telling the story with these modifiers and you want your story to be as accurate as possible. And you’re going to use the most specific modifiers. Now CMS gave us the X modifiers, and I’m gonna do a presentation on that. X modifiers XUXP, X, U, x, P, x, E, and x s. Those modifiers for Medicare purposes are considered to be more specific than modified 59, and they don’t want you using 59.
When you can use one of those modifiers. Xs, Xp, Xu, and I think, Xe. They in the back of your CPT book. Normally, CPT does not put level, modifiers. For the anatomical location, they do have those in there, and they do have, the XU modifiers in the book for convenience. because Medicare wants you to use the most specific modifier, and sometimes 59 is not it.
So watch out for that. And as we wrap up, the other thing is, do not use modifiers on codes that have multiple procedures involved. that applies to multiple body parts. Like your, And when I say don’t use modifiers, I’m talking mostly about anatomical modifiers. So if you take a lesion off, guess what?
That lesion sometimes will say leg, arm, neck, trunk. It’s too many body parts involved. So they don’t want you to put a left L T or R T on that. So watch out for that. you’re gonna use modifiers when you are dealing with the same physician on the same day, for the same days of surgery. So once again, you know, if somebody have a procedure on Monday, then come back on Wednesday, have one.
They may not be related. Now, of course if they related, we got to modifier 7, 6, 7, 7, 8, in the front of your book. So read those modifiers. modifiers can be used also on rated radiology. They can be used on other diagnostic testing, like, echoes, but always be guided. by your instruction in your CPT book or in your HPX Level 2 book.
They will tell you when you can use certain modifier or if you can use a modifier at all. If it tells you no modifier, don’t try to put one on there. It’s not going to work. Sometimes you and the coder have to think, I don’t have any instruction. Do I need a modifier? Now you got to go back and tell the story.
Okay. If you need one, why? Why do you need a modifier? Ask yourself why? What am I trying to convey? What am I trying to tell? And once you answer that question, now you know if I need a modifier, I don’t need a modifier, and if so, which one do I need? Alrighty, well look, that’s our very brief intro, what, review, fundamental review, review.
What did I call this? I called this, Fundamental Modifier Review. It’s just the fundamentals and it’s just very brief. You can take this and pass a test with it, cause you as a coder, you gotta learn to think critically. You got to learn to ask those questions. When you take a test, always remember, what is the question not asking you?
There’s some time that we have to think that way as well. Well, look, I’m a sign off for May. For this one, we may have more. Okay. and I want you to follow me on Facebook, LinkedIn, and we’re going to be on TikTok real soon. I look forward to talking to you on the next video. In the meantime, think critically.