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Male Speaker: For the younger people that are newer to coding, a modifier is something that gets attached to a CPT code that allows you to tell the payer more about what you did with that code. And we are going to go through the list of the most commonly used modifiers in podiatry. I hope everybody in this room knows these. You should.
Each toe has its own modifier and each foot, of course, has its own modifier. The one that may -- the one question that often gets asked with these is, where, for purposes of modifiers, does the toe end and the foot begin? Meaning, if I do work at that first MPJ, should it be a T modifier or should it be an RT or a LT modifier? And the answer is, if it is at or proximal to the MPJ, then you use RT or LT. If it is distal to the MPJ, then you use a T modifier. And you should be using these whenever you can. Itâs always best to give the payer as much information as you possibly can.
So, if you do a simple PIPJ arthroplasty, right, if itâs a right second toe PIPJ arthroplasty with a 28285, you should be appending a T6 to that to tell them which toe you did it on. If you do a bunionectomy at the first MPJ, that should be RT or LT. If you do a lesser MPJ capsulotomy, that should be RT or LT. So, again, if itâs at or proximal to the MPJ, use RT or LT. If itâs just in the toe, use a T modifier.
22 modifier is for increased procedural service. Meaning, you did more than what is typically required for that code. You spent more time. There was more difficulty. The severity of the condition warrants this.
Iâm going to go through examples of when you should and when you should not which I think is the best way to illustrate this. Itâs when much more considerable more effort and time is necessary to complete that procedure than what is typically necessary for that code.
So, a good example would be a failed first MPJ implant where youâre going to make an incision, dissect down, remove the implant, and then convert it to a fusion. Well, unfortunately, the only thing we can code for that is first MPJ fusion. Not fair, but thatâs the rule. The removal of the implant was performed at the same surgical site through the same incision and same everything else as the fusion. Therefore, you cannot code for the removal of the implant and the fusion. You could only code for the first MPJ fusion. But we know that that is a very different procedure, the one I just described, than is a straight clean primary first MPJ fusion.
Getting that implant out could be a lot of work, right? Especially if itâs been in there for a long time. That would be a situation where it would be appropriate to code for first MPJ fusion with a 22 modifier. If you do that, you should send in a claim form and the op report and separate from those two items, a narrative describing what you did. And yes, thereâs a lot of overlap between that in the op report, but a narrative of what all this extra work was, why it required so much more effort, why there was more time, more risk involved, and why the 22 modifier is appropriate. Thatâs a legit example.
One of my former residents who asks me some weird coding questions, recently, I got a text from him and it started with, âSo, a patient came in for nail care and they had 11 toes.â
I knew where this was going. And yes, he asked it and the answer was, âNo, thatâs not the spirit of the 22 modifier.â Itâs not what weâre getting out here. So, I hope those two examples illustrate when it is appropriate and when it is not appropriate.
25 modifier is for a separately identifiable evaluation and management. And I can do 30 minutes on what is a separately identifiable evaluation and management just on that. But because weâre covering all modifiers, we canât do that. And simply stated, the definition of a separately identifiable evaluation and management is that you can -- separately identifiable from the procedure, of course, that you can separate the E&M and all of its components from the documentation that goes along with the procedure and from the actions that go along with the procedure. Take every part of the E&M out of that and have it still stand alone as its own separate entity. Again, you should be able to take all of the components of the E&M out of the procedure and have it stand on its own.
So, hereâs a good example of one that is not. So, I was recently asked -- patient had an ulcer debridement and they had been using a topical agent and I made the decision to switch what they were using topically. Can I code a separately identifiable E&M for the effort and the thought that went into switching what they were using topically? No, because that does not stand on its own completely separate from the debridement and a simple illustration of that is, the O, right, the exam, that led to your decision to do the debridement, the exam that goes with the debridement is the same as the exam that led to the decision to switch what youâre using topically.
So, if you pull the exam portion out of the E&M, youâve left a hole in the debridement part of the visit. It has to stand on its own as its own service. There are no such thing as automatic separately identifiable E&Ms, right?
And to break, somebody asked me a really good question. On a first-time patient, a new visit, can I do a separately identifiable E&M with the debridement? And the answer was, âProbably and you should be because Iâm sure you did it, but the documentation has to support it.â And the example I gave was on this new patient.
Iâm sure we all do a separately identifiable E&M on that new patient with a diabetic foot ulcer. We educate them, and tell them what a diabetic foot ulcer is, and that itâs really bad, and we have to do this kind of offloading, and we talk nutrition and arterial supply, and activity, and all that stuff. But the documentation has to support that a separately identifiable E&M was performed. And in that note, right, if itâs SOAP, and the P section of that new patient visit that got a debridement says, âPlan: Sharp debridement with a 15 blade down the SubQ with force runners, 300 meters of tissue removed.â The M of the E&M is missing, right? Thereâs no management there and the auditor whoâs -- hasnât met their quota for the month, is going to say, âWhereâs the M, whereâs the management? All these tells me is that you debrided it,â and we would say, âWell of course I talked to them about that,â but it has to be documented. So thatâs a separately identifiable E&M.
50 modifier is for bilateral procedures if the procedure that was performed has a bilateral indicator.
This is a mistake a lot of people make and they miss appropriate reimbursement for a procedure performed bilaterally because they didnât check to see if that code had a bilateral indicator.
Some do, some do not, there is absolutely no pattern to it, you canât say this kind has it and these donât, or forefoot do and mid-foot doesnât, thereâs no such thing, you just have to check. If you do a procedure bilaterally, the first question is, does it have a bilateral indicator?
If it does, you use the 50 modifier, if it does not, you do not use the 50 modifier. So again, you do a procedure, the same procedure bilaterally, when you go to code it, first question, does it have a bilateral indicator, and whether it does or it does not, dictates the coding.
If it does, you use the 50, if it does not, you do not, so you need to have a way to very easily answer this question. Hopefully, whatever coding resource you use, answer that question for you, I use the APNA Coding Resource Center.
I have no relationship with it to disclose, I subscribe to it just like you guys do. So this resource tells you very easily whether it does or does not. So if you look at the code on the bottom, youâll see thatâs a Keller bunionectomy and following across the bottom, it tells you whether it has a global period, whether you can do an assistant feed, the RVUs, and then you see on bottom, Bilat, why.
That means it does have a bilateral indicator. If you look at the code thatâs three down from the top, thatâs a condylectomy, so 2A, 288, that does not have a bilateral indicator. So Iâll tell what it looks like both ways.
So letâs say we do a bilateral Keller, does it have a bilateral indicator? We look up Keller, 28292, it does.
Because it does, that means you do use the 50 modifier to code it, and when it does have a bilateral indicator, you use one unit on one line with a 50 modifier.
Putting the 50 tells them you did it twice. So one unit, one line, 50 modifier, no RT or LT because if you did it bilaterally, thereâs only two options, they know that you did RT and LT. So donât put laterality modifiers with 50 modifier, it can lead to the claim getting kicked out.
And then because you did it twice, you should bill twice what you normally bill. So whatever you submit when you do a Keller, double that on what you charge them, and they should honor the 50 modifier, recognizing that it was done bilaterally.
Now letâs look at it in another way. We do this procedure bilaterally, does it have a 50 modifier, we look it up, and it does not. So now you do not use the 50 modifier, and when there is not a 50 modifier, the appropriate coding is to list that code twice, one RT and LT and one gets a 59.
No it does not matter which one you put the 59 on, just pick one. So if you do a procedure bilaterally, use the 50 modifier if thereâs a bilateral indicator. If thereâs not a bilateral indicator, this is how to do it.
Whatever coding tool youâre using, I suggest too, you should make it very easy for you to answer that question as to whether it does or it does not. The 59 modifier, this room and our profession and is very familiar with. This is a separate, unrelated procedure, so like buinonectomy and tailor bunionectomy, right, one gets a 59.
We cannot do 1st MPJ capsulotomy and bunionectomy, that would be unbundling. So 59 modifier indicates a second, unrelated procedure, but I want to spend some time on these X modifiers. These were introduced by Medicare a couple of years ago as an alternative to the 59, and when they first came out, the messaging from me and the APMA Coding Committee was, âYou donât have to worry about it, they are not making us do it. The 59 modifier is still fine, donât waste your time worrying about it unless a payer tells you, you have to.â
And thatâs been our messaging, because why throw something else into the mix and why complicate it, but over the last year or two, starting to think there may be some usefulness to these X modifiers as a substitute for 59 modifier for Medicare only.
So this is Medicare only. Only Medicare, as of today, I put the question mark there, because somebody else could pick it up tomorrow, but as of today, only Medicare recognizes X modifiers, and you can use an X instead of a 59, and this XS, that applies to a lot of stuff that we do, right, nails and callouses, bunionectomy, tailor bunionectomy.
The XS is an appropriate substitute, and a lot of people didnât want to have to worry about it because they didnât want to do something, or they didnât want to have to use one where they can only do it for Medicare people, but the reason Iâm revisiting it is, there are a lot of audits that deal with the 59 modifier, and there are a lot of payment cuts dealing with the 59 modifier, where theyâll cut a 59 modifier thing in half.
For a Medicare patient, if the XS is appropriate, itâs not a bad idea to use it instead of 59, and thatâs suggesting that this would allow you to do anything inappropriate or that it gets you through if youâre coding nefariously, which of course Iâm not suggesting, but if there is some kind of audit or program that they run based on 59, youâre not going to show up, and maybe that saves you the hassle of a letter, or it saves you the headache of having to provide documentation.
Again, not suggesting in any way that this allows you to get away with anything, but it might save you some aggravation, and it might keep you off the radar for 59 modifier stuff if youâre not using it as much. Just a thought as to where these X modifiers may help you.
I want to finish up with the modifier options that you have for coding during a global period. For E&M coding during the global, there is only one option, for procedural coding the post-operative global, there are three options, and that is an important distinction, because itâs two very different options that you have for what you can and cannot do during the global, if itâs an E&M versus if itâs a procedure, two very different situations.
One, E&M modifier and that is the 24 modifier, which says it is an unrelated E&M during the global, unrelated. Thatâs different from unexpected. Different from â I found a different diagnosis. This is something a lot of our colleagues get wrong and they fail audits based upon unrelated E&Ms.
So an example would be somebody whoâs post-op bunionectomy, and theyâre at their fourth week post-op visit and they say, âYou know what? Since Iâm here, Iâve been wanting to ask for 20 years why my toenails are yellow.â
And you do an E&M of dystrophic yellow toenails, totally unrelated to the bunion. Thatâs a legit unrelated E&M during the global.
But letâs look at another example. Letâs say, weâve all been there, you do a transmetatarsal amputation and the patientâs home, and theyâre one week post-op. And they think they see redness at the closure site. And they donât call you, what do they do? They go to the ED. And what happens as soon as the red foot lands in the ED? Admit, theyâre in, right? Now they get admitted, now you get consulted. And you donât have residents. And you drive 20 minutes to the hospital and spend another 10 minutes finding the patientâs room, but theyâre not there, because theyâre down in radiology. You walk another 10 minutes down to radiology and get there and find them and start to unwrap the bandage and then the radiology tech yells at you and says, âWe canât do that down here, you have to wait until they get back upstairs.â We know this game, right? Weâve all been there. Then you chase him up and do the visit and hunt for the chart for 10 minutes, if your hospital hasnât converted it to electronic charting yet. And by the time weâre done with this nightmare, itâs two and half hours in and you decide this patient doesnât need surgery. Itâs post-op infection, they need intravenous antibiotic. And thatâs it. And maybe itâs dehisced a little, and you pop a suture or two.
People make the mistake and rightfully so, we think we should get paid for that, right? I want to get paid for that. I know everybody here does also. But people make the mistake of finding a different diagnosis, like, post-op infection or wound dehiscence or stitch abscess or something. And thinking that itâs appropriate to code an E&M with a 24 modifier because they found a different diagnosis.
But thatâs not what it says, it says unrelated. The tinea pedis is â or, sorry, the onychomycosis, the yellow toenails, thatâs unrelated to the bunion. But the post-op infection, the dehiscence, the stitch abscess, whatever other creative diagnosis you could find, is related to that TMA. So there are occasions where itâs appropriate and certainly those where itâs not appropriate. So thatâs the only E&M option available during the global.
We have three procedural options. So the 79 modifier is sort of the 24 modifier equivalent for a procedure and that is in unrelated procedure. So post-op bunion person that needs a 11730 portion, that avulsion because they had an ingrown, unrelated procedure. Totally legit, you could do those procedures, you should get paid for those procedures, 79 modifier, unrelated procedure. Notice, it makes no mention of the location, 79 unrelated, does not say anything about the place of service or where that procedure was performed, unrelated procedure anywhere, including an ingrown in the office.
78 modifier is a related procedure if itâs done in the hospital or operating room, hospital or â sorry, operating or procedure room. So 79 was unrelated, you could do it anywhere. 78 is a related procedure if itâs in the operating or procedure room. So 10-day post-op bunionectomy person that has a hematoma that needs to be incised and drained, thatâs related.
If you do it in the office, you cannot use the 78 modifier. If you do it in the operating or procedure room, you can use a 78 modifier.
Two-week or let say one month post-op TMA person at the wound care center, where thereâs got a little bit of dehiscence and you debrided at the wound center, canât code for it with a 78 modifier. It has to be in the operating or procedure room. What is a procedure room? Thatâs a room in your office that is set aside and dedicated for procedures. If itâs a room that somebody got their toenails cut in five minutes ago, thatâs not a procedure room.
So there is some ambiguity there, itâs not exactly clear what is and whatâs not. What I tell people when they ask is, âIf an auditor shows up and says you coded a 78 in the office, I want to see your procedure room.â When you show it to them, they need to be able to without any questions say, âOh, I get it. I see what you mean, thatâs totally a procedure room.â If you show it to them and theyâre like, âThereâs toenails on the ground or I see an orthotic grinder in here,â thatâs not a procedure room. It needs to legitimately be a procedure room in order for you to use this in the office setting.
58 is the third option we have during the global. This is for a staged procedure. This was staged and planned, you knew the second procedure was coming and it is important that you document your expectation that a staged second procedure was coming.
So good example, letâs say today, thereâs a gross gas gangrene that we do on open guillotine TMA on. And we know weâre going back in a couple of days to clean it up, debride more approximately, maybe close, whatever, to fit and revamp.
That second procedure, youâre going to be able to use the 58 modifier on because it was staged. You knew it was coming, like, taking off an Ilizarov external fixator, six weeks after putting it on. That was staged. You knew that was coming. But in order to buy the ticket, to use the 58 modifier on the second procedure, you must document your intent to use it when the first procedure is performed. So with that, guillotine TMA.
In todayâs op-note, you should dictate, âThis was left open. We are going to need to return for more work as part of these staged multiple procedure effort,â and I would suggest you say, âWhy?â right, to salvage this patientâs limb, or to save as much as we can, or whatever. Important that you document the plan to use the 58 subsequently, that then allows you to use the 58 modifier subsequently.
And then when you do use it, you should again document this is a staged procedure as planned from the get go. So then, some people say, âWhy didnât you just say that on all of them, then I can use the 58 if I need it later, right?â If you do an amputation today, and you document clean, healthy, clean margins, adequate bleeding, primary closure performed, you canât then use the 58 three weeks later when it dehisces, itâs one or the other, right? So you need to document your intent to use it subsequently.
Any procedure that has a 90-day global, if it has a 90-day global, only 90s, if it has 90-day global, that global period extends to 24 hours before the procedure.
If it has a 90-day global, the global actually started 90 days prior to the procedure. So if we go in today to the hospital, and thereâs a gross abscess that weâre going to I&D tomorrow, the I&D that weâre doing tomorrow has a 90-day global that extends into today, and eats todayâs E&M. But we have the option for a 57 modifier on an E&M that is done 24 hours preceding a procedure that has a 90-day global where the decision for surgery was made. So if we go in today and do that consult on the gross abscess and say Iâm going to do an I&D tomorrow, you can put a 57 modifier on todayâs E&M because the decision for surgery was made today.
If, on the other hand, where you have a patient at the hospital that were rounding on and on Friday, you write, âWeâre going to take this patient to the operating room on Monday for, letâs say, primary closure of something,â right? Thatâs not a good example because itâll be in a global. Weâre going to take this patient in the OR on Monday for an amputation. Fridayâs fine because theyâre not in the global, right? Mondayâs 90-day global amp, that global extends to Sundays, you can cover Friday, you can code for Saturday. But if Sundayâs note says, vital stable, all questions answered, patient to the OR tomorrow, the decision for surgery wasnât made, it was made on Friday. You cannot use the 57 modifier there, only when the decision for surgery was made.
If youâre doing skin subs in your office, hopefully you know these, the FTA does not want us to call them skin subs anymore. They are now supposed to be referred to as CTPs, Cellular and/or Tissue-based Products for wounds.
And if you think that some of these newer, fancy, amniotic options, theyâre not really skin subs, right, theyâre not substitutes for skin, thatâs why the change. So weâre supposed to be calling skin subs CTPs that hasnât really caught on. Most of us are still saying skin subs, but weâll say it right for the rest of our time here.
If youâre putting a CTP on in your office, you code for the application, that 1527, whatever, right? And then you code for the product. If youâre putting one of these on in your office, it has a cue code. All of these CTP options that you would be using in your office, they have cue codes. We have always had to document how much we used and how much we wasted. We now need to code how much we used and how much we wasted. You have to code how much you used and how much you wasted. You do that with what was a brand new modifier, January 1, 2017. And that modifier is the JW modifier. So the appropriate way to code this, if you put one of this in your office, itâs the first line should be the application code, 15275 if itâs foot under a certain size, right?
Then line two should be the cue code for that product with the number of units you used with the JC modifier. The third line should be that same cue code again with the number of units wasted with a JW modifier. When you add together the number of units used and the number of units wasted, it should equal to total number of units that came out of the box. They are paying both.
Today, my own conspiracy theory, which is based on nothing, is that theyâre making us do this for a reason. And if I was the one right in the checks at Medicare, I would not be wanting to pay for 44 square centimeters of product to cover a sub one four-square centimeter ulcer.
I think theyâre making us do this for a reason. So think about that when you decide which products to use and which size products to use. They are paying for both now, but my own opinion is theyâre making us do this for a reason. They want to know how much is getting wasted.
If you are using plain film x-ray in your office, starting January 1, 2017, you need to attach a modifier to your x-ray codes. If youâre doing plain film in your office, for Medicare only, this is only for Medicare, you need an FX modifier on your x-ray codes. If you havenât been doing it and youâre going getting paid, itâs because nobodyâs come to look at your x-ray machine yet. They can and they have, and thatâs â could be a problem.
For Medicare only, if youâre using plain film x-ray, put an FX modifier on your x-ray codes, and now, just using digital isnât enough. You need to know for Medicare which type of digital x-ray youâre using. You need to ask, âIs my digital x-ray unit CR or DR?â If you donât know, look at whatâs written on the machine, or call the manufacturer and ask, âIs my digital x-ray CR or is it DR?â If it is a CR digital x-ray, you need an FY modifier on your x-ray codes. This started 11-18.
So, for Medicare, if youâre using plain film, you need an FX modifier. If youâre using CR digital radiography, you need an FY modifier. If youâre using DR digital x-ray, you donât need any modifier.
Thanks so much for your attention. Enjoy the rest of the morning or afternoon.
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