JE Medicare Part B Processing Changes for Use of CPT Modifier 22 - Effective September 16, 2013

Noridian has identified a claim processing difference between contractors. This notification is to make all Part B providers served by Jurisdiction E (JE) aware of this difference. 
Palmetto GBA, the current J1 contractor, requires the submission of documentation along with the claim. Documentation required with the claim is a concise statement and operative report which is either entered in Item 19 of the CMS-1500 claim form for paper claims or submitted with an electronic claim via the fax attachment process. Failure to submit the appropriate information results in a denial of the claim. Claims submitted with CPT modifier 22 are reviewed on an individual basis. Additional reimbursement allowance will be dependent on the documentation.
Noridian pays claims with the CPT modifier 22 at the established fee schedule rate. Providers may appeal for additional payment with sufficient documentation demonstrating the work performed was substantially greater than typically required and explains why the surgery was unusual.

When appealing:

• Redetermination requests require a separate, concise statement explaining the necessity for additional reimbursement be included.
• Need operative report or separate letter
• Medical Review addresses each request individually with no assurance of additional payment 

Example

Treatment Description	CPT/Modifier
Pharyngolaryngectomy, with radical neck dissection; with reconstruction	31395 22

Resource
Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.2 “Billing Requirements for Global Surgeries” – Unusual Circumstances at  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/bp104c12.pdf 

READ MORE - JE Medicare Part B Processing Changes for Use of CPT Modifier 22 - Effective September 16, 2013

What is a Modifer?

A modifier is a two-digit numeric or alpha numeric character reported with a CPT/HCPCS code,

when appropriate. Modifiers are designed to give Medicare and commercial payers additional
information needed to process a claim.
A modifier provides the means by which a physician can report or indicate that a service or
procedure that has been performed has been altered by some special circumstances(s), but has
not changed in its definition or code. Modifiers also enable health care professionals to effectively
respond to payment policy requirements established by other entities. These codes should be
entered in item 24D on the Form CMS-1500 or electronic equivalent.

Some examples of when a modifier may be appropriate include:
A service or procedure has both a professional and technical component, but both
components are not applicable

A service or procedure was performed by more than one physician and/or in more than

one location

A service or procedure has been increased or decreased in complexity or performance

 

An adjunctive service was performed

 

A bilateral procedure was performed

Unusual events occurred during a procedure or service

Placement of a modifier after a CPT or HCPCS code does not insure reimbursement. A special

report may be necessary if the service is rarely provided, unusual, variable or new. The special
report should contain pertinent information and adequate definition of the procedure or service
performed that supports the use of the assigned modifier. If the service is not documented, or the
special circumstance is not indicated, it is not considered appropriate to report the modifier. A
report should not be submitted unless requested.

Some modifiers are informational only (e.g., -24 and -25) and do not affect reimbursement. They

can however, determine if the service will be covered or denied.
Other modifiers such as modifier -22 (increased procedural services) will increase the
reimbursement and protocol for many third-party payers if documentation supports the use of
this modifier. Modifier -52 (reduced services) will usually equate to a reduction in payment.

There will be times when the coding and modifier information issued by CMS differs from the
AMA’s coding advice in the CPT manual regarding the use of modifiers. A clear understanding
of Medicare’s rules is necessary in order to assign the modifier correctly. It is the responsibility of
each provider or practitioner submitting claims to keep abreast of the Medicare program
requirements.

The use of modifiers is an important part of coding and billing for health care services. Modifier

use has increased as various commercial payers, who in the past did not incorporate modifiers
into their reimbursement protocol, recognize and accept CPT/ HCPCS codes appended with
these specialized billing flags.

Correct modifier use is also an important part of avoiding fraud and abuse or noncompliance

issues, especially in coding and billing processes involving the federal and state governments.
Several of the top billing errors involve the incorrect use of modifiers.

This article courtesy of: http://www.medicarenhic.com/providers/pubs/ModifierBillingGuide0611.pdf
 

READ MORE - What is a Modifer?