California State Medicaid Will Discontinue Use of ZS Modifier as of December 31, 2013

Public Comment Forum: HIPAA Code Conversion for Local Modifier ZS 

As part of the continuing effort to comply with the federally mandated Health Insurance Portability and Accountability Act (HIPAA), the following change is slated to be effective for dates of service on or after December 1, 2013: 
The Department of Health Care Services (DHCS) will discontinue use of local modifier ZS, which is used to bill for the full professional (26) and technical (TC) components of a procedure. 

This article provides information about a public comment forum for this change. 

Claim Completion
Providers will be instructed to use one of the following scenarios when submitting a claim for split- billable procedures or services: 

Scenario 1: The facility and physician each bill for their respective component of the service with modifiers 26 or TC. Each provider/facility submits their own claim with one line of service and the appropriate modifier (26 or TC) designating the service they provided. 

Scenario 2: Full Fee Billing – The physician bills for both the professional and technical components and subsequently reimburses the facility for the technical component, according to their mutual agreements. The physician submits a CMS-1500 claim form and completes two separate claim lines as follows: The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC).

Scenario 3: Standard Billing – The facility bills for both the technical and professional components and reimburses the physician for the professional component, according to their mutual agreements. The facility submits a UB-04 claim form and completes two separate claim lines as follows: The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC). 

TAR Completion
Providers will be instructed to use one of the following scenarios when submitting a Treatment Authorization Request (TAR) for split-billable procedures or services: 

Scenario 1: One TAR and one provider for both the professional (26) and technical (TC) components of service. The TAR must be submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC). 

Scenario 2: One TAR and two different providers for the professional (26) and technical (TC) components of service. One of the providers submits the TAR on behalf of both providers of the two components of service (26 and TC). Both providers use the same TAR for claim submission. The TAR is submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC). 
This is the preferred method for two different providers. 

Scenario 3: Two TARs and two different providers for the professional (26) and technical (TC) components of service.
Each provider submits their own TAR with one line of service and the appropriate modifier designating the service (26 or TC) they provided or will provide. 

Comment Period
Notice is hereby given that DHCS will conduct written public proceedings, during which time any interested person or such person’s duly authorized representative may present statements, arguments or contentions relevant to the action described in this notice. 

There has been a correction to the start date of the comment forum, which was previously posted as September 15, 2013. The comment forum will begin September 16, 2013, and end at 4:00 PM on October 30, 2013. The proposed changes will be available by clicking the “Public Comment Forum Coming: HIPAA Code Conversion for Local Modifier ZS” line in the NewsFlash area of the Medi-Cal website. This link will direct providers to the “Medi-Cal Comment Forum” where they can view the article. Providers may call the Telephone Service Center (TSC) at 1-800-541-5555 or visit the Medi-Cal website if they have questions or need additional information.

Courtesy of : http://files.medi-cal.ca.gov/pubsdoco/forum_21767_1.asp

Use of Modifier 25 Explained

By Betsy Nicoletti from Physicians Practice

Just the facts, ma'am. It is easy to find both CPT and CMS guidance about the use of modifier 25, and if a group needs "just the facts," the facts are only a few keystrokes away. But if the facts are clear, why does the Office of Inspector General's (OIG) website continue to post notices of physician practices and hospital systems paying back millions of dollars for the use of modifier 25? Do healthcare providers not understand the facts or is there judgment in the interpretation of the guidance in the use of modifier 25?

Let's start with the facts. Modifier 25 is appended to an Evaluation and Management (E&M) service (never to a procedure) to indicate that a significant and separately identifiable E&M service was provided on the same day as a minor surgical procedure. Although I joke that any procedure done on me is a major procedure, a minor procedure is defined as a procedure with zero to ten global days in the CMS Physician Fee Schedule. The catch is the definition of a "significant and separately identifiable." Healthcare professionals often mistakenly believe that assessing the condition and deciding to perform a minor procedure entitles them to an E&M service on the same day as the procedure. This is incorrect.

The National Correct Coding Initiative (NCCI) manual states "The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. …If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.

"And the CMS manual states that "The initial evaluation is always included in the allowance for a minor surgical procedure."

That is, the payment for evaluating the condition and deciding to perform a procedure is considered part of the payment for the procedure, unless there is a significant and separately identifiable service performed. Do not report a separate E&M service for a planned procedure. Many minor procedures on healthy patients do not require a separate E&M, such as lesion destruction or punch biopsy. The clinician is paid for the evaluation of the lesion as part of the destruction or biopsy. It is permissible to report an E&M service for an unrelated problem or when the problem being evaluated wouldn't necessarily result in the procedure. A patient presents with abnormal vaginal bleeding. The physician assesses the problem prior to deciding to perform the endometrial biopsy. Or, a patient presents with multiple non-healing wounds, and the physician addresses the patient's vascular status, compliance with diabetic regimen, and decides to debride an ulcer. Both the procedure and the E&M may be reported.

So, do healthcare providers not understand the facts or is there judgment in the interpretation and guidance? Both are true. On the provider side, we haven't heeded the statement that the decision to perform a minor procedure is included in the payment for the minor procedure. On the payer side, what constitutes significant and separately identifiable work is not clearly defined. Physician practices might remember this mantra: Using modifier 25 is not always or never, but sometimes. CMS, payers, and the OIG have the use of modifier 25 on their watch lists, so stop and consider whether the E&M service is above and beyond evaluating the site and deciding to perform the service.

Courtesy of: http://www.physicianspractice.com/coding/use-modifier-25-explained?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=05092013

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