Level Up Your Modifiers

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Are you reporting Level I modifiers when Level II modifiers may provide more specificity?

Did you know there are two levels of modifiers?

Both levels of modifiers further define services reported with CPT or HCPCS codes and do not change the CPT/HCPCS code description.

Level I CPT modifiers are developed by AMA, and CMS develops level II HCPCS modifiers.

HCPCS Level II modifiers may be appended to CPT codes, and CPT Level I modifiers may be appended to HCPCS Level II codes.

Let’s focus on the Level II HCPCS Modifiers, specifically, the anatomic modifiers.

Coronary artery modifiers

LC – Left circumflex coronary artery

LD – Left anterior descending coronary artery

LM – Left main coronary artery

RC – Right coronary artery

RI – Ramus intermedius coronary artery

Eyelid modifiers

E1 – Upper left eyelid

E2 – Lower left eyelid

E3 – Upper right eyelid

E4 – Lower right eyelid

Photo (without modifiers) by Ani Kolleshi on Unsplash

Finger modifiers

FA – Left hand thumb

F1 – Left hand second digit

F2 – Left hand third digit

F3 – Left hand fourth digit

F4 – Left hand fifth digit

F5 – Right hand thumb

F6 – Right hand second digit

F7 – Right hand third digit

F8 – Right hand fourth digit F9 – Right hand fifth digit

Photo (without modifiers) by Luis Quintero on Unsplash

Toe modifiers

TA – Left foot great toe

T1 – Left foot second digit

T2 – Left foot third digit

T3 – Left foot fourth digit

T4 – Left foot fifth digit

T5 – Right foot great toe

T6 – Right foot second digit

T7 – Right foot third digit

T8 – Right foot fourth digit

T9 – Right foot fifth digit

Photo (without modifiers) by Cristian Newman on Unsplash

Coronary artery modifiers

LC – Left circumflex coronary artery

LD – Left anterior descending coronary artery

LM – Left main coronary artery

RC – Right coronary artery

RI – Ramus intermedius coronary artery

(Sorry, I couldn’t find a photo)

Laterality modifiers

LT – Left side of the body

RT – Right side of the body

I find that we sometimes default to modifier 59 or XS, but included in the definition of modifier 59 (X-), is the statement, “when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used”.  

Check your major payers’ policies.  Most payers are consistent with CMS correct coding guidance.  They require anatomical modifiers that identify the area or part of the body for procedures performed on the eyelids, fingers, or toes.

CPT is a registered trademark of the AMA

Does it matter if we don’t report the diagnosis?

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I met with a physician this week to explain why the coders were sending him so many queries.

The physician consistently documented “compatible with” in the impression.  No matter the medical condition, he always prefaced it with “compatible with.”

I explained that according to ICD-10-CM Coding Guidelines, Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services, H. Uncertain diagnosis, the coders cannot assign codes for conditions documented as “probable,” “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty.

The coders had to either assign diagnosis codes from the signs/symptoms or other reasons for the encounter documented in the clinical indication or send the notes back to him to clarify the language he entered in the impression.

According to the physician, when he documents consistent with, it means the patient has the condition.

He then went on the “remind” me that coders are not physicians and they should not question his documentation.

I had to remind him that coders are translators.  We translate his documentation according to coding guidelines into codes that are universally understood by payers and other health agencies, and other entities that track and report health statistics.

He asked if it matters if we don’t report the codes. 

Kelli wanted to respond so bad!  Her voice was shouting in my head!

Instead, I explained to him (as I shared with you in Documentation Improvement), according to the World Health Organization (WHO), “ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion that allows for:

• easy storage, retrieval and analysis of health information for evidence-based decision-making;
• sharing and comparing health information between hospitals, regions, settings, and countries; and
• data comparisons in the same location across different time periods.”

ICD-10-CM codes are not only used for processing health insurance claims. The codes are used to track epidemics, pandemics, factors that influence health status and external causes of diseases, and compile worldwide mortality statistics.

So, yes, it matters if we don’t report the codes.

AMA E/M Technical Corrections (3/9/21)

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Well, we’re in our third month of the 2021 changes for outpatient evaluation and management services. 

Just when we’re starting to feel comfortable abstracting the Medical Decision-Making according to the guidelines that went into effect on January 1^st, AMA posted technical corrections on March 9^th that are retroactive to January 1^st.

The technical corrections are highlighted in blue on the document.

In my opinion, the highlighted areas color in some of the grey areas, and that’s a good thing.