(Medicare Claims Processing Manual)

Modifier - 50 is used to report bilateral procedures that are performed at the same operative session as a single line item.  Do not use modifiers RT and LT when modifier - 50 applies.  Do not submit two line items to report a bilateral procedure using modifier - 50.  Modifier - 50 applies to any bilateral procedure performed on both sides at the same operative session.   The bilateral modifier -50 is restricted to operative sessions only.   Modifier - 50 may not be used:    To report surgical procedures identified by their terminology as bilateral, or   To report surgical procedures identified by their terminology as unilateral or bilateral.   The unit entry to use when modifier - 50 is reported is one.  20.6.3 - Modifiers -LT and -RT  (Rev. 1, 10- 03-03)  Modifiers - LT or -RT apply to codes, which identify procedures, which can be perf ormed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries.  Modifiers - LT and -RT should be used whenever a procedure is performed on only one side.  Hospitals use the appropriate - RT or - LT modifier to identify which of the paired or gans was operated upon.   These modifiers are required whenever they are appropriate.   20.6.4 - Use of Modifiers for Discontinued Services  (Rev. 4204, Issued: 01- 17-19, Effective: 01- 01-19, Implementation: 01- 07-19)  A. General  Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers.   Modifier - 73 is used by the facility to indicate that a procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well bei ng of the patient after the patient had been prepared for the procedure (including procedural pre -medication when provided), and been taken to the room where the procedure was to be performed, but prior to administration of anesthesia. For purposes of bill ing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.   Modifier - 74 is  used by the facility to indicate that a procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circum stances that threatened the well being of the patient. This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of ane sthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep  sedation/analgesia, and general anesthesia. T his modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.   Coinciding with the addition of the modifiers - 73 and - 74, modifiers - 52 and - 53 were revised. Modifier - 52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. The modifier provides a me ans for reporting reduced services without disturbing the identification of the basic service. Modifier - 53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.  The elective cancellation o f a procedure should not be reported.   Modifiers - 73 and - 74 are only used to indicate discontinued procedures for which anesthesia is planned or provided. B. Effect on Payment  Procedures that are discontinued after the patient has been prepared for the p rocedure and taken to the procedure room but before anesthesia is provided will be paid at 50 percent of the full OPPS payment amount. Modifier - 73 is used for these procedures. As of January 1, 2016, for device -intensive procedures that append modifier - 73, we will reduce the APC payment amount for the discontinued device -intensive procedure, by 100 percent of the device offset amount prior to applying the additional payment adjustments that apply when the procedure is discontinued as modified by means of a final rule with comment period and published in the November 13, 2015 Federal Register (80 FR 70424). Beginning January 1, 2017, device -intensive procedures are defined as those procedures requiring the insertion of an implantable device, that also hav e a HCPCS - level device offset greater than 40 percent. From January 1, 2016 through December 31, 2016 device -intensive procedures were defined as those procedures that involve implantable devices that are assigned to a device- intensive APC (defined as those APCs with a device offset greater than 40 percent). Beginning January 1, 2019, device -intensive procedures are defined as procedures that involve the surgical implantation or insertion of an implantable device that is assigned a CPT or HCPCS code (including single -use devices) and has a device offset amount that exceeds 30 percent of the procedures mean cost.  Procedures that are discontinued, partially reduced or cancelled after the procedure has been initiated and/or the patient has received anesthesia will be paid at the full OPPS payment amount. Modifier - 74 is used for these procedures.  Procedures for which anesthesia is not planned that are discontinued, partially reduced or cancelled after the patient is prepared and taken to the room where the pr ocedure is to be performed will be paid at 50 percent of the full OPPS payment amount. Modifier - 52 is used for these procedures.  20.6.5 - Modifiers for Repeat Procedures  (Rev. 1, 10- 03-03)  Two repeat procedure modifiers are applicable for hospital use:    Modifier - 76 is used to indicate that the same physician repeated a procedure or service in a separate operative session on the same day.    Modifier - 77 is used to indicate that another physician repeated a procedure or service in a separate operative session on the same day.    If there is a question regarding who the ordering physician was and whether or not the same physician ordered the second procedure, the code selected is based on whether or not the physician performing the procedure is the same.   The procedure must be the same procedure.  It is listed once and then listed again with the appropriate modifier.   20.6.6 - Modifiers for Radiology Services  (Rev. 1599, Issued: 09- 19-08, Effective: 10- 01-08, Implementation: 10- 06-08)  Modifiers - 52 (Reduce d Services), -59, -76, and - 77, and the Level II modifiers apply to radiology services.   When a radiology procedure is reduced, the correct reporting is to code to the extent of the procedure performed.  If no HCPCS code exists for the service that has bee n completed, report the intended HCPCS code with modifier - 52 appended.   EXAMPLE:  CPT code 71020 (Radiologic examination, chest, two views, frontal and lateral) is ordered.  Only one frontal view is performed.  CPT code 71010 (Radiologic examination, ches t: single view, frontal) is reported.  The service is not reported as CPT code 71020- 52.  20.6.7 - CA Modifier  (Rev. 1, 10- 03-03)  Definition:   Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission.  20.6.8 - HCPCS Level II Modifiers (Rev. 1, 10- 03-03)  Generally, these codes are required to add specificity to the reporting of procedures performed on eyelids, fingers, toes, and arteries.  They may be appended to CPT codes.  If more than one  level II modifier applies, the HCPCS code is repeated on another line with the appropriate level II modifier:   EXAMPLE:  Code 26010 (drainage of finger abscess; simple) done on the left thumb and second finger would be coded:   26010FA  26010F1  The Level II  modifiers apply whether Medicare is the primary or secondary payer.   20.6.9 - Use of HCPCS Modifier -FB  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Effective January 1, 2007, the definition of modifier - FB is  Item Provid ed Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples) .  See the Medicare Claims Processing Manual, Pub 100- 04, Chapter 4, 61.3 for instructions regarding charges for items billed with the -FB modifier.    The OPPS hospitals must report modifier - FB on the same line as the procedure code (not the device code) for a service that requires a device for which neither the hospital, nor the beneficiary, is liable to the manufacturer.  Hospitals must report modifie r -FB on the same line as the procedure code for a service that requires a device when the manufacturer gives credit for a device being replaced with a more costly device.   20.6.10 - Use of HCPCS Modifier -FC  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Effective January 1, 2008, the definition of modifier - FC is  Partial credit received for replaced device.   See the Medicare Claims Processing Manual, Pub 100 -04, Chapter 4, 61.3 for instructions regarding charges for items  billed with modifier - FC. OPPS hospitals must report modifier - FC for cases in which the hospital receives a partial credit of 50 percent or more of the cost of a new replacement device under warranty, recall, or field action.  The hospital must append modifier - FC to the procedure code (not the device code) that reports the services provided to replace the device.   20.6.11 - Use of HCPCS Modifier   PO (Rev. 4204, Issued: 01- 17-19, Effective: 01- 01-19, Implementation: 01- 07-19)   Effective January 1, 2015, the definition of modifier - PO is  Services, procedures, and/or surgeries furnished at excepted off- campus provider -based outpatient departments.  This modifier is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an excepted off-campus provider -based department of a hospital. See 42 CFR 413.65(a)(2) for a definition of campus.   This modifier should not be reported for remote locations of a hospital (defined at 42 CFR 413.65(a)(2)), satellite facilities of a hospital (defined at 42 CFR 412.22(h)), or for services furnished in an emergency department.   Reporting of this modifier i s voluntary for CY 2015; reporting of this modifier is required beginning January 1, 2016. We note that beginning in CY 2019 we are finalizing a policy to pay for clinic visits (G0463) billed at excepted off -campus provider based departments (departments t hat bill modifier PO on their claim lines) at the PFS -equivalent amount.  The PFS -equivalent amount paid to nonexcepted off -campus PBDs is 40 percent of OPPS payment (that is, 60 percent less than the OPPS rate) for CY 2019. We are phasing this policy in  over a two year period. Specifically, half of the total 60- percent payment reduction, a 30- percent reduction, will apply in CY 2019. In other words, these departments will be paid 70 percent of the OPPS rate (100 percent of the OPPS rate minus the 30- percent payment reduction that applies in CY 2019) for the clinic visit service in CY 2019. 20.6.12 - Use of HCPCS Modifier   PN (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  A. General   Effective January 1, 2017, the definition of modifier PN is  Nonexcepted service provided at an off -campus, outpatient, provider -  based department of a hospital . This modifier was established to  identify and pay nonexcepted items and services billed by an off-campus department of a provider.  Nonexcepted items and services are described in the regulations at 42 CFR 419.48.  B. Effect on Payment