Reimbursement Policy updates

Modifier 79 reminder: Professional

A recent review of our claim trends has identified that many providers are not billing appropriately for modifier 79.  According to Appendix A in the CPT Professional Edition, modifier 79 is used to indicate that a procedure or service is an “…unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period”.  If the current procedure or service does not fall within the postoperative period of a previously performed 0, (same day), 10 or 90 day postoperative period, by the same provider or a provider in the same group practice, please carefully consider the definition of modifier 79 when adding the modifier to a procedure or service.

 

Modifier 63 reminder: Professional

According to Appendix A of the CPT Professional Edition codebook, modifier 63 is only used when an invasive procedure is performed on neonates or infants up to a present body weight of 4 kg to indicate significantly increased complexity and physician or other qualified health care professional work commonly associated with these patients.  Unless otherwise designated, this modifier should only be appended to the procedures/services identified in the modifier description.  Additionally, based on the modifier description, modifier 63 is not valid for use with evaluation and management, anesthesia, radiology, pathology/laboratory, or medicine codes.  Furthermore, many procedures performed on infants for correction of congenital abnormalities include additional difficulty or complexity that are inherent to the procedure and are identified by the code nomenclature and the CPT parenthetical “do not use modifier 63 in conjunction with…”  These codes are also identified in Appendix F of the CPT Professional Edition codebook.  Please note, incorrect reporting of modifier 63 may result in claim denials.

 

ICD-10-CM Coding Guidelines and Laterality: Professional

With the adoption of ICD-10-CM code set, we were introduced to diagnosis codes that now indicate the laterality of a condition.  At present, diagnosis code descriptions indicate whether the condition is present on the left, right or exists bilaterally.  A recent review of our claim denial trends has identified that many providers are not billing appropriately in regards to laterality. For specific guidance for reporting a diagnosis that designates a condition on the left and right versus a bilateral diagnosis refer to the ICD-10-CM Official Guidelines for Coding and Reporting FY 2019, specifically, the General Coding Guidelines Section and the Chapter Specific Sections. Please carefully consider the information contained in the ICD-10-CM Coding Guidelines when trying to decide between reporting a condition using left diagnosis and right diagnosis codes versus a bilateral diagnosis code.