Again, I know that not everybody buys this, but this is a really important resource for all of us who are paying attention to the CPT code. I know the coders and billers have them, but many of the proceduralists don't own this and I find this to be really helpful. So if you guys have an interest in this and it pays for itself shortly, get one. Okay, so I'm going to talk about CPT code modifier. And I know that many of the coders and billers are familiar with these, but I think many of the providers are less familiar. So I think it's important to at least know how these modifiers can benefit you. So basically the modifiers are used as a way to supplement the information or adjust the care descriptions to provide the extra care that you guys have for, oops, sorry, that you're rendering that service provided by the service. And they can actually improve your billing when you use it appropriately. Again, talk to your billers to get familiar with this. I'm going to start with the modifier 63. I know that Guru referred to this. This is the most common one that I've encountered, meaning that if you take care of a baby that's under four kilos, that modifier can add more value to your work. Obviously they're smaller, more fragile, takes more work, care, stress, et cetera, adds to the complexity of the work. And in fact, it adds another 20% value to what you do. So don't forget to add that in there. Now, one of the things that I've learned is that the coders review your notes, but if you have the weight hidden somewhere on page three, it's going to take them a little more time to look for it. So I usually put that in the first page bolded so that it's obviously what the weight is and they can use that to add the modifier when they're adding your codes to the billers. So now the other area that is often confusing is the concept of being a co-surgeon versus an assistant. And I'll review that a little bit. The modifier 62 is really the co-surgeon modifier. Basically what it means is that when two surgeons, or in this case, a two proceduralists are required to perform a specific procedure, each can bill for the procedure and add a modifier too so that they will actually, basically they're doing some spontaneous surgery together in a situation. Again, it doesn't apply as much in the cath lab, but definitely applies in the valves. So heart transplant was one example thrown out, but the hybrid valve implants that we often do these days also can apply. So how is that paid? Basically when you have two surgeons or a surgeon and interventionist billed together as co-surgeons, you get 125% of the reimbursement and they're split evenly across both disciplines. So the surgeon gets 62.5, you get 62.5%. That's really helpful. I think it's really important to make sure that before you join in the procedure, you clarify with the surgeon so that there's an agreement on both sides that you guys are considered co-surgeons. I've encountered earlier on where the surgeons would write me down as an assist and obviously I didn't feel that way. So after some discussion, there was clarity and both sides agreed that these are co-surgical procedures and that way there's less argument. So I think the expectation has to be clear upfront. And then again, this is very useful in a hybrid procedure in both an OR or a cath lab. All right. Now 80, 81, 82 are basically the assistant codes. And again, there are some controversy here and I'll just go through it quickly to illustrate the controversy. So basically if the procedure, it can only allow for those codes that allow for assistance, meaning that most of what we do in the cath lab don't really apply, but it happens to apply for valve implants. So then that's just important to know. So it depends on the code that you're using. Now I stress this in yellow and bold because it's really important to refer to your Medicare physician fee schedule to determine if a co-surgeon or an assistant surgeon is allowed. So you've got to talk to your billers to say how this might work out to your advantage or not. Medicaid allows us to actually vary from state to state. So that's why this is not black and white. We talked a little bit about it as a group, but just want to make sure people know that this may vary depending on which state you work on. It also can depend on payers. Now in California, we know that we'll modify 80 for Medicaid and 82 for the federal payers like Medicare. We also learned that Medicare will accept 80 if that's not at a training center. Again, I want to just make sure people know that these rules can vary depending on where you live, the region, and your state guidelines. 80, basically one physician assists another in performing a procedure. If the assistant surgeon assists a primary surgeon and is present for the entire operation or a substantial portion, then they count. Again, you just basically will put in your code and the biller will add in the 80 as an appended modifier. This is not typical, as I said, for congenital heart interventions, but where it applies is going to be in the valve or a hybrid valve implants. And I know that that's just going to increase in number over time. 81 is really similar to 80, except this is for a short amount of time, whether you're going in to do something quickly and then leaving and you're not there for all that. But again, this is a gray area. That's why you have to talk to your surgeon, how you guys want to designate this. He may view you as a surgeon because he did the stenotomy, put him on bypass, and then had to do everything else, and you're just the assistant to him. So again, I've emphasized a communication with the surgeon is really important before you go into the OR or the hybrid lab. A second surgeon, again, this is minimal or part of the procedure, and you can use the 81 modifier. 82 is the gray one. It's only limited to teaching hospitals. Most of us work in teaching hospitals. And of course, in the case that you have a qualified resident surgeon is not available. The gray area is qualified. What is qualified? On the surgical side, a qualified surgeon may be one who can hold the retractor properly and know when to suck blood when the surgeon asks for it. That doesn't apply in the cath lab because most of your fellows are not interventional cardiologists. So therefore, I usually just write the resident is either observing, and if I have another cath person there, I would call that person the assistant, and you guys decide it internally. But this is a hard one because this isn't a gray area for the hybrid OR or for the hybrid valve implant. A lot of times, there's a surgical resident there as well as the interventional fellows. That's why it's not so easy to clean this up. So most of us in the past have recommended to avoid using this, but again, I want to emphasize that this is a gray area. It depends on your state, your area, your region, and your payer allowances. As I said, Medicare accepts 82, but we'll accept 80 in non-teaching hospitals. But many times, in the past, we've, as a group, recommended to stay away from this code. Now, there's a couple of ones that were 58, 59, or actually for multiple procedures, whether it could be in a stage procedure where, again, this applies for those procedures that are part of the global period. Again, not very common for us, but if you happen to do a hybrid myeloid valve, let's say, and later on, you find that you need a line for a clot, and you put that line in for catheter-directed TPA, and you have to bring them back later on for repeat angiography, that might apply. Again, this is rare, but just throw it out there so people know. 59 is also used for more than two or more procedures that are performed during the same visit at a different site. Again, this should only be used when there are no other appropriate modifiers to describe the relationship of these two procedures. It should never be used to try to unbundle a code. That would be illegal, or try to bypass the NCCI edits, and you guys can work that out with your coders for that. To me, a good example is when you take a patient to the cath lab, under one anesthesia, you might do a CART cath, and then an electrophysiologist comes in to do an EP study, and that would be the same account. That's where this could be useful. The 24-25 are actually EMN codes, basically applied to the interventionist who's going to see the patient. Again, these only apply for those procedures that are under the global period between 10 to 90 days, and again, it doesn't apply other than the rare hybrid procedures that we do. 24 relates to the fact that you have an unrelated evaluation and management by the same physician or another person in the same specialty group in that post-operative global period. So, for example, you did a hybrid mitral implant, and then you're asked to evaluate a vascular occlusion during the global period. You can actually still bill for that, even though you were the co-surgeon within that global period. 25 is only for patients who you see a patient, and you bring the kid to the cath lab because of an urgency, again, within the global period, if the patient had a procedure that was within the global period. So, here's an example where you saw a patient in the ER. You bill that ER visit, and, of course, the kid needs an urgent cath, and you bring him to the cath lab same day. You can bill that with this modifier. That's different from an elective procedure where you see the patient in the morgue for HNP, and then you bring them to cath lab later on. That doesn't apply in that situation. 78 is basically reporting an unplanned return to the operating room or a procedure by the same physician following an initial procedure or related procedure during that post-op period. Only applies for those procedures that have a global period, again, mostly going to be hybrid-related. Again, this is where I find that it's useful for the hybrid procedures between you and the co-surgeon, and you are billing as the co-surgeon. This is just a graph to show the kind of payments you get based on these modifiers. So, in other words, rather than getting nothing, you get something. So, for these numbers, you get anywhere from 78, you get 80% of the amount, 80, 20%, similar to 82, you get 16% for 81, and then 62 as a co-surgeon. That's one where I find it to be very helpful. You get 62.5% of the billing. And then finally, for MUEs, Mark Hoyer talked about this a little bit, stands for medically unlikely edits. I have no idea why they use that term, but basically think of it as the unit of service you can use for any specific CPD code rendered by one provider on the same day of service to the same patient. So, for example, embolization codes, this was discussed for the veins, 37241, or the arteries, 37242, you're allowed two times to submit that code within that same patient. For pulmonary angioplasty, interestingly, for 92991, you're allowed one, and subsequent, you actually have the MUA7, so you can actually use that code, 92998, up to seven times within the same patient. Now, I want to just point out some disparities in MUEs for congenital heart disease, and again, this has, just to let people realize that we are victims of some disparities. For example, coronary stenting allows three MUEs. They can stent the left coronary, right coronary, and circumflex, and build it as initials three times. On the other hand, when we do pulmonary artery stenting, you're allowed one time to either do a unilateral or a bilateral under both the normal and abnormal conditions. And if you add up all the RVUs, it doesn't count, it doesn't add up to the coronary stent codes. Again, this is just some of the things that we as interventional, congenital interventionists are facing, but again, this is why we formed this group to try to work these things out and try to improve reimbursements for our community. So with that, I'm going to end.

CPT code modifiers

medical billing

surgeon communication

multiple procedures

reimbursement issues