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Modifiers　

According to the American Academy of Orthopedic Surgeons in 2008 who gave the best explanation, "A modifier is a 2-digit code appended to a Current Procedural Terminology (CPT) code to indicate that a service or procedure has been altered by some specific circumstance, but has not changed in its definition or code."

A provider may append a modifier to indicate a special circumstance when reporting a service. During individual and multiple procedures and evaluation and management (E&M) services modifiers may be appended.

When a provider submits a claim with a CPT code, the appropriate modifier is "linked to the CPT code on the claim form." The CPT code is listed on the left side of box 24D, and the modifier is linked on the right side of box 24D.

The Utilization of modifiers are mandatory in many circumstances in chiropractic and are listed below.

Modifier -AT

Acute treatment (this modifier should be used when reporting service 98940, 98941, 98942.) Without this modifier, Medicare will consider your treatment as maintenance and not cover the service.

Modifier -GA

Waiver of liability statement issued as required by payer policy, individual case. Used when an advance beneficiary notice (ABN) is required to be issued based on payer policy. Charges should be shown as covered. Beneficiary will be held liable. It is mandatory for all 97- - - codes.

Modifier -GP

Services delivered under an outpatient physical therapy plan of care. This modifier is only reported when the service is performed as a part of the therapy plan of care. These services are "sometimes therapy" codes that can be performed by non-therapists. Report this modifier only when a qualified therapist performs the service. If a non-therapist performs the service do not report this modifier.

E-How reports " According to the Centers for Medicare and Medicaid Services, a GP modifier means that "Services [are] delivered under an outpatient physical therapy plan of care." This means that the service or item received was a part of a preexisting plan of care for physical therapy created by Medicare doctors and physical therapists. It also means that the service was performed in an outpatient setting. Put another way, the patient did not need to be admitted to a hospital to obtain the service. In order for physical therapy to be covered by Medicare, a plan of care is required. A GP Modifier will accompany a code that more explicitly explains what the service was. For example, if a patient received in-home hydrotherapy as a part of his physical therapy plan of care, the code for in-home physical therapy (G0151) would be accompanied by the letters "GP." The full code would be G0151GP.

Modifier -GX

Notice of liability issued, voluntary under payer policy. Use the modifier GX to provide beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute. Must be used with non-covered charges only.

According to the American Chiropractic Association " 　Item or service expected to be denied because it is not a covered service—ABN signed.　 Modifier GX went　into effect April 5, 2010. The GX modifier will be used when providers want to indicate they have used an ABN to voluntarily notify a beneficiary that a statutorily non-covered Medicare service will not be covered. It is important to remember that Medicare only requires the ABN be used to inform beneficiaries when services will be denied as "not reasonable and necessary" (e.g., maintenance care spinal CMT). Providers are not required to inform patients that non-covered services (e.g., exams, x-rays, physical medicine services) will not be covered.

Modifier -GY

Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit. Charges should be shown as non-covered. Beneficiary is held liable for charges. This would be used for services that are excluded such as dental. The patient/beneficiary should know that such services are not covered.

The American Chiropractic Association reports" Non-Covered Service (Services Which Are Statutorily Excluded or Do Not Meet the Definition of Any Medicare Benefit.) Used on All Non-Covered Services (anything NOT spinal CMT).　 This modifier is required on all services other than manual manipulation of the spine, including x-rays, extra-spinal CMT, therapy modalities, and exams. Please note that you do not use GY on maintenance care spinal CMT.

Modifier -GZ

Item or service expected to be denied as not reasonable and necessary. Charges should be shown as non-covered. Provider is held liable for charges. Use this when an ABN hasn't been issued, but the provider determines after the service has been performed that it was not covered. For example, a laboratory test that has specific diagnosis criteria, but the hospital doesn't check the diagnosis until after the test has been run.)

Modifier -25

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. May be used only with E/M visit codes (with status indicator V) within the following code ranges: 92002-92014, 99201-99285, 99431, G0101, G0175, G0245, G0246, G0344 G0380-G0384 ~~Modifier used on an E/M code when it is reported with a procedure code that has a outpatient payment status indicator (OPSI) of "S" or "T." However, this does not preclude the provider from reporting this modifier with E/M codes that are assigned to an OPSI other than the "S" or "T" as long as the procedure meets the definition of "significant, separately identifiable E/M service" (Medicare Claims Processing Manual, chapter 4, section 20.6, Medicare transmittal 1045, September 1, 2006.)

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 identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). 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 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. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

As reported by Wikipedia, V-Codes or ICD-9 V Codes, the majority of the v-codes are not applicable to chiropractic and therefore modifier -25 should be used as clinically indicated:

1. V01 Contact with or exposure to communicable diseases

2. V02 Carrier or suspected carrier of infectious diseases

3. V03 Need for prophylactic vaccination and inoculation against bacterial diseases

4. V04 Need for prophylactic vaccination and inoculation against certain viral diseases

5. V05 Need for other prophylactic vaccination and inoculation against single diseases

6. V06 Need for prophylactic vaccination and inoculation against combinations of diseases

7. V07 Need for isolation and other prophylactic measures

8. V08 [Asymptomatic] human immunodeficiency virus (HIV) infection status

9. V09 Infection with drug-resistant microorganisms

10. V10 Personal history of malignant neoplasm (i.e. cancer)

11. V11 Personal history of mental disorder

12. V12 Personal history of certain other diseases

13. V13 Personal history of other diseases

14. V14 Personal history of allergy to medicinal agents

15. V15 Other personal history presenting hazards to health

16. V16 Family history of malignant neoplasm

17. V17 Family history of certain chronic disabling diseases

18. V18 Family history of certain other specific conditions

19. V19 Family history of other conditions

20. V20 Health supervision of infant or child

21. V21 Constitutional states in development

22. V22 Normal pregnancy

23. V23 Supervision of high-risk pregnancy

24. V24 Postpartum care and examination

25. V25 Encounter for contraceptive management

26. V26 Procreative management

27. V27 Outcome of delivery

28. V28 Encounter for [antenatal] screening of mother

29. V29 Observation and evaluation of newborns for suspected conditions not found

30. V30 Single liveborn

31. V31 Twin birth mate liveborn

32. V32 Twin birth mate stillborn

33. V33 Twin birth unspecified whether mate liveborn or stillborn

34. V34 Other multiple birth (three or more) mates all liveborn

35. V35 Other multiple birth (three or more) mates all stillborn

36. V36 Other multiple birth (three or more) mates liveborn and stillborn

37. V37 Other multiple birth (three or more) unspecified whether mates liveborn or stillborn

38. V38 NOT USED

39. V39 Liveborn unspecified whether single twin or multiple

40. V40 Mental and behavioral problems

41. V41 Problems with special senses and other special functions

42. V42 Organ or tissue replaced by transplant

43. V43 Organ or tissue replaced by other means

44. V44 Artificial opening status

45. V45 Other postprocedural states

46. V46 Other dependence on machines

47. V47 Other problems with internal organs

48. V48 Problems with head neck and trunk

49. V49 Other conditions influencing health status

50. V50 Elective surgery for purposes other than remedying health states

51. V51 Aftercare involving the use of plastic surgery

52. V52 Fitting and adjustment of prosthetic device

53. V53 Fitting and adjustment of other device

54. V54 Other orthopedic aftercare

55. V55 Attention to artificial openings

56. V56 Encounter for dialysis and dialysis catheter care

57. V57 Care involving use of rehabilitation procedures

58. V58 Encounter for other and unspecified procedures and aftercare

59. V59 Donors

60. V60 Housing, household and economic circumstances

61. V61 Other family circumstances

62. V62 Other psychosocial circumstances

63. V63 Unavailability of other medical facilities for care

64. V64 Persons encountering health services for specific procedures not carried out

65. V65 Other persons seeking consultation

66. V66 Convalescence and palliative care

67. V67 Follow-up examination

68. V68 Encounters for administrative purposes

69. V69 Problems related to lifestyle

70. V70 General medical examination

71. V71 Observation and evaluation for suspected conditions not found

72. V72 Special investigations and examinations

73. V73 Special screening examination for viral and chlamydial diseases

74. V74 Special screening examination for bacterial and spirochetal diseases

75. V75 Special screening examination for other infectious diseases

76. V76 Special screening for malignant neoplasms

77. V77 Special screening for endocrine nutritional metabolic and immunity disorders

78. V78 Special screening for disorders of blood and blood-forming organs

79. V79 Special screening for mental disorders and developmental handicaps

80. V80 Special screening for neurological eye and ear diseases

81. V81 Special screening for cardiovascular respiratory and genitourinary diseases

82. V82 Special screening for other conditions

83. V83 Genetic carrier status

84. V84 Genetic susceptibility to disease

85. V85 Body mass index

86. V86 Estrogen receptor status

Modifier -TC

Technical component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier 'TC' to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.

Modifier -59

As reported by CMS... "Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. 　Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. 　However, when another already established modifier is appropriate, it should be used rather than modifier 59. 　Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

Modifier -59 is an important NCCI (national correct coding initiative) -associated modifier that is often used incorrectly. 　For the NCCI, its primary purpose is to indicate that two or more procedures are performed at different anatomic sites, or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.

NCCI edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters. 　Carrier processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. 　Modifier -59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.

References:

1. With the exception of the following references, all modifier information comes from Ingenix Encoder Pro Professional, 2011

2. Modifier Changes for 2008, American Academy of Orthopedic Surgeons, Retrieved from: http://www.aaos.org/news/aaosnow/may08/managing4.asp

3. What is Medicare Modifier GP?, E-How, Retrieved from, http://www.ehow.com/about_6418012_medicare-gp-modifier_.html　

4. Medicare Modifiers, American Chiropractic Association, Retrieved from, http://www.acatoday.org/content_css.cfm?CID=2035

5. Medicare Modifier 59 Article, Center for Medicare Services, Retrieved from, http://www.cms.gov/MedicaidNCCICoding/05_Modifier%2059%20Article.asp