Appendices

APPENDIX DESCRIPTION A CPT and HCPCS Modifiers.Add the appropriate Level 1 CPT modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951.This table includes only common modifiers, any valid modifier may be used if it is appropriate to the situation. B Add-On Codes - Procedures that are commonly carried out in addition to the primary procedure performed and must never be reported as stand-alone codes.These codes are exempt from the multiple modifier '51' as are all codes that specify that they should be listed in addition to the main procedure. C Separate Procedures - Procedures that are stand alone codes.These codes are exempt from the multiple modifier '51'. D Drugs Administered Other Than Oral Method - List of drugs and biologicals that can be injected either subcutaneously, intramuscularly, or intravenously reimbursed at invoice cost. APPENDIX A - Level I and Level II Common Modifiers This appendix lists the modifiers that are most commonly used in treating injured workers.The absence of a modifier from this appendix does not preclude its use in the appropriate situation. (a) Anesthesia Modifiers. 1. Physical Status Modifiers.Physical status modifying units will be reimbursed if the patient is ranked in one of the following three categories.Physical status is included in CPT to distinguish various levels of complexity of provided.Example: 00100-P3 the anesthesia service Physical Status Modifiers Description Modifying Unit Value P3 P4 P5 A patient with severe systemic disease. A patient with severe systemic disease that is a constant threat to life. A moribund patient who is not expected to survive without the operation. 2. CPT and HCPCS Modifiers for Anesthesia Services.Add the appropriate Level 1 CPT modifier or HCPCS Level II modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951. Level 1 CPT Modifier Description 23 Unusual Anesthesia Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia.This circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service. 47Anesthesia by Surgeon Regional or general anesthesia provided by the surgeon may be reported by adding the modifier '-47' to the basic service.(This does not include local anesthesia.)Note: Modifier '-47' or 09947 would not be used as a modifier for the anesthesia procedures. AA Anesthesia services performed personally by anesthesiologist This modifier must be used in conjunction with the appropriate service code to denote medical direction of one or two concurrent anesthesia procedures involving residents in a teaching environment. Payment for the physician's medical direction service shall be made at 100% of the allowance for the service performed by the physician alone. QK Medical Direction of Multiple Anesthesia Procedures This modifier must be used in conjunction with the appropriate service code to denote medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. Payment for the physician's medical direction service shall be made at 50% of the allowance for the service performed by the physician alone. QX CRNA Service This modifier must be used to report services of a CRNA: with medical direction by a physician.This medical direction modifier is used when the physician medically directs two, three, or four concurrent procedures involving interns, residents, CRNAs and AAs.This allows 50% of the fee to be paid to the employer. QY CRNA Service This modifier must be used to report medical direction of one CRNA by an anesthesiologist. This allows 50% of the fee to be paid to the employer. QZ CRNA Service This modifier is used to report CRNA service: without medical direction by a physician.This allows 100% of the fee to be paid to the employer. (b) CPT Modifiers for Clinical Laboratory Services.Add the appropriate Level 1 or Level II CPT modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951. Level 1 CPT Modifier Description -90 Reference (Outside) Laboratory When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier '-90' to the usual procedure number. -91 Repeat Clinical Diagnostic Laboratory Test In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91.Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one time, reportable result is all that is required.This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing).This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. (c) HCPCS Modifiers for Durable Medical Equipment, Oxygen Delivery and Orthotic and Prosthetic Procedure Codes. Add the appropriate Level II HCPCS modifier to the five-digit code to identify the specific circumstance. Level II CPT Modifier Description KH DMEPOS item, initial claim, purchase or first month rental KI DMEPOS item, second or third month rental KJ DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to 15 KM Replacement of facial prosthesis including new impression/moulage KN Replacement of facial prosthesis using previous master model KR Rental Item, billing for partial month LL Lease/Rental (use the 'LL' modifier when DME equipment rental is to be applied against the purchase price) MS Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty NR New when rented (use the 'NR' modifier when DME which was new at the time of rental is subsequently purchased) NU New equipment QE Prescribed amount of oxygen is less than one liter per minute (LPM).This shall be reimbursed at 50% of the published rate of the appropriate service code. QF Prescribed amount of oxygen exceeds four liters per minute (LPM) and portable oxygen is prescribed.This shall be reimbursed at 150% of the published rate of the appropriate service code. QG Prescribed amount of oxygen is greater than four liters per minute (LPM).This shall be reimbursed at 150% of the published rate of the appropriate service code. RP Replacement and repair -RP may be used to indicate replacement of DME, orthotic and prosthetic devices which have been in use for sometime.The claim shows the code for the part, followed by the '-RP' modifier and the charge for the part RR Rental (use the 'RR' modifier when DME is to be rented) UE Used Durable Medical Equipment (d) CPT and HCPCS Modifiers for Physicians' Services.Add the appropriate Level 1 CPT modifier or HCPCS Level II modifier to the five digit code. Level 1 CPT Modifier Description 21 Prolonged Evaluation When the face to face or floor/unit services(s) provided is prolonged and Management Services or otherwise greater than that usually required for the highest level of evaluation and management service within a given category, it may be identified by adding modifier 21 to the evaluation and management code number.A report may also be appropriate 22 Unusual Procedural When the work required to provide a service is substantially greater Service than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required) Note: This modifier should not be appended to an E/M service. Level 1 CPT Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service 26 Professional Component (PC) 50 Bilateral Procedures 51 Multiple Procedures 52 Reduced Service 54 Surgical Care Only Description (continued) It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately indentifiable /M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided.As such, different diagnoses are not required for reporting of the E/M services on the same date, This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service.Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. For significant, separately identifiable See non-E/M services, see modifier 59 Certain procedures are a combination of a physician component and a technical component.When the physician component is reported separately, the service may be identified by adding modifier -26 to the usual procedure number. Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session, should be identified by adding modifier '50' to the appropriate five digit code.The addition of the modifier '50' to the second bilateral code allows 50% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the eligible provider for the second bilateral procedure. When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies(eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed.The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code.Note: This modifier should not be appended to designated "add-on" codes.The addition of the modifier 51 to the second and subsequent procedure code allows 50% of the allowable fee in 114.3 CMR 40.05 to be paid to the eligible provider. Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances, the service provided can be identified by its usual procedure number and addition of the modifier 52 signifying the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.The fee will be based on individual consideration. When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier 54 to the usual procedure number.This allows 85% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the surgeon. Level 1 CPT Modifier Description (continued) 55 Postoperative When one physician performed the postoperative management and Management Only another physician performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the physician that provided the postoperative management. 59 Distinct Procedure If a procedure or service not normally reported together was or Service performed on the same day, the fee will be based on the full maximum fee of 100% of the payment group for the distinct procedure or service. 62: Pertains to Two Under certain circumstances the skills of two surgeons (usually with Surgeons different skills) may be required in the management of a specific surgical procedure. These circumstances may be identified by adding the modifier 62 to the procedure code used by each surgeon for reporting his services. The addition of the modifier62 to the procedure codes allows 57.5% of the allowable fee contained in 114.3 CMR 40.05 to be paid to each surgeon. No separate fee may be charged for assisting surgical services in these cases; it is included in the total surgical fee and may be paid to both physicians based upon their agreement. 66: Pertains to Team Surgery Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) carried out under the "surgical team" concept.Such circumstances may be identified by each participating physician with the addition of modifier 66 to the basic procedure number used for reporting services. Payment of each physician should be as agreed upon by the team and the insurer. 76 Repeat Procedure by It may be necessary to indicate that a procedure or service was the Same Physician repeated subsequent to the original procedure or service.This circumstance may be reported by adding modifier 76 to the repeated procedure or service. 77 Repeat Procedure by The physician may need to indicate that a basic procedure or service Another Physician performed by another physician has to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service. 78 Return to the Operating It may be necessary to indicate that another procedure was performed Room for a Related during the postoperative period of the initial procedure (unplanned Procedure During procedure following initial procedure).When this procedure is related the Postoperative Period to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedure see modifier 76). 79 Unrelated Procedure The physician may need to indicate that the performance of a or Service by the Same procedure or service during the postoperative period was unrelated to Physician during the the original procedure.This circumstance may be reported by Postoperative Period. using modifier 79.(For repeat procedures on the same day see modifier 76). Level 1 CPT Modifier Description (continued) 80: Pertains to Assistant Surgical assistant services may be identified by adding the modifier Surgeons 80 to the usual procedure number.This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon. 81 Minimum Assistant Minimum surgical assistant services are identified by adding the Surgeon. modifier 81 to the usual procedure number.This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon. 82 Assistant Surgeon (when qualified resident surgeon not available)The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code numbers.This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon. AS Assistant at Surgery Physician assistant, nurse practitioner or clinical nurse specialist services for assistant at surgery. SA Nurse Practitioner Nurse practitioner rendering service in collaboration with a physician.This indicates reduced payment. -SM Second Option Second surgical opinion. -SN Third Option Third surgical opinion. Appendix B - Add-On Codes Summary of CPT Add-On Codes for CPT 2008.Add on codes are identified in the CPT book with a "+".The CPT book is the final authority on the identification of add-on codes. CODE APPENDIX C-- Codes Exempt from Modifier -51 Summary of CPT Separate Procedure Codes Exempt from Modifier 51 for CPT 2008.This list is not exhaustive.The CPT book identifies all codes exempt from modifier 51 and is the final authority on the matter. CODE Appendix D: Drugs Administered Other Than Oral Method CODE