Understanding when to use modifiers will ensure correct coding and prompt reimbursement.

Surgical modifiers play a crucial role in accurate coding, claim submission, and reimbursement optimization. This article provides a review of the surgical modifiers commonly used in ambulatory surgical centers (ASCs).

Modifier rules can vary among payers, making it imperative to avoid assuming universality in applying one payer’s guidelines to others. Commercial payers may have distinct policies from the Centers for Medicare and Medicaid Services (CMS), necessitating consultation of payer-specific guidelines or provider representatives for accurate modifier usage.

The use of anatomical and bilateral procedure modifier billing is a prime example of how different payers have different rules for modifier use.

ANATOMICAL MODIFIERS AND BILATERAL PROCEDURES

Anatomical modifiers provide additional specificity when coding ophthalmic surgical procedures. These include -E1 (left upper eyelid), -E2 (left lower eyelid), -E3 (right upper eyelid), -E4 (right lower eyelid), -LT (left eye), and -RT (right eye). Proper utilization of these modifiers ensures accurate coding and billing for ophthalmic procedures. Not all ICD-10 diagnosis codes include laterality, but when a code does, ensure that the diagnosis code and appended modifier are telling the same story.

When coding bilateral procedures for Medicare payers in the ASC setting, the modifier -50 is not recognized for payment purposes and if used may result in incorrect payment. For example, the bilateral repair of ectropion on the lower right and left lid could be coded as 67914-RT and 67924-LT, or as 67924-E2 and 67924-E4, depending on the payer’s rules. For Medicare patients and ASC billing, you would not use the bilateral modifier and bill as 67914-50 as reported for the physician claim. Most corresponding ICD-10 codes for this procedure include laterality.

CMS gives this clear direction on their preference: “Bilateral procedures furnished in ASCs should be reported as either a single unit on two separate lines (appending the RT and LT modifiers) or with “2” in the units field on one line, in order for the bilateral procedures to be paid correctly.”¹ However, as a testament to the ever-changing rules of coding, this guidance was retired earlier this year, in March 2023. The American Academy of Ophthalmology (AAO) recommends following these bilateral billing rules until CMS publishes updated guidelines. Commercial payers may have different bilateral billing rules.

TERMINATED PROCEDURES

Modifiers also play a significant role in cases of terminated procedures. The -73 modifier is used when a procedure is discontinued before the administration of anesthesia, resulting in the ASC receiving 50 percent of the allowable payment. Conversely, the -74 modifier is used when a procedure is discontinued after anesthesia administration, ensuring the ASC is paid 100 percent of the allowable. For example, if a patient experiences a severe allergic reaction after anesthesia has been administered, resulting in the termination of a cataract surgery (CPT code 66984), the ASC should append modifier -74 to indicate the procedure was discontinued after anesthesia.

Detailed documentation in the operative report is essential to specify the reason for termination, services provided, supplies used, and services that would have been performed if the surgery had continued.²

Modifier -53 is for physician use only and is not used by ASCs.

If multiple procedures are planned but none of them are performed, only the primary procedure is reported with the appropriate discontinued procedure modifier. If one procedure is completed and a second is started but not completed, code the first procedure with no modifier and report the second procedure with modifier -74. Any additional planned procedures not started are not reported. ASC surgical procedures billed with modifier -74 are subject to multiple procedure reduction if the surgical procedure itself is subject to the multiple procedure reduction.³

When a procedure using separately reimbursable devices is terminated, there are specific guidelines for billing and reimbursement. The most common in ophthalmology are intraocular lens (IOL) procedures. In cases where an IOL insertion was planned but not performed, the ASC’s payment will be adjusted by deducting the allowance for the unused IOL before calculating the facility’s payment. If you have disposed of the IOL without receiving any credit from the supplier, it is advisable to write a letter to Medicare, informing them that the IOL was opened and subsequently wasted. This will allow you to seek reimbursement for the wasted IOL. However, if the supplier has provided full credit for the unused IOL, it is appropriate to include the modifier -FB on Medicare claims. Modifier FB should be appended to all devices, supplies, or drugs obtained at no cost to the provider. Alternatively, if the supplier has given only partial credit, the modifier -FC should be applied on Medicare claims. Modifier -FC should be appended to all devices, supplies, or drugs that are furnished with a partial credit of 50 percent or more for a replacement device.⁴ It is essential to adhere to these guidelines to ensure accurate billing and appropriate reimbursement.

MULTIPLE PROCEDURES

Multiple procedures performed during a single operative session require careful coding and billing to appropriately maximize reimbursement. No modifiers—including the -51 modifier (multiple procedures)—are required to indicate that multiple procedures are performed during the same surgical session. Each procedure should be billed separately, starting with the procedure with the highest relative value unit (RVU). The payment for the first procedure is 100 percent, while subsequent procedures performed in the same session receive a reduced payment of 50 percent.

GLOBAL PERIOD SURGICAL MODIFIERS AND NCCI EDITS

In ophthalmology, ASCs typically have a same-day global period, making surgical modifiers such as -58 (staged or related procedure by the same physician), -78 (return to the operating room for a related procedure), and -79 (unrelated procedure during the postoperative period) rare in ASC billing.

For example, a patient requires a repair of retinal detachment by pneumatic retinopexy (CPT 67110) and a paracentesis of the anterior chamber with removal of aqueous (CPT 65800) in the global period of a previous retinal detachment surgery in the same eye. Both procedures are billed out with the appropriate laterality modifier with no modifier -51, and no modifier -78 on the ASC claim, with the pneumatic retinopexy listed first. Medicare payers reimburse both procedures, but some commercial payers deny the paracentesis and only reimburse the pneumatic retinopexy. These two codes are not bundled but the CPT descriptor of 65800 includes the words “separate procedure” indicating that some payers will only pay for this when performed as a stand-alone procedure.

It is important to note that ASC National Correct Coding Initiative (NCCI) edits are the same for physician NCCI edits when it comes to the use of modifier -59 for those payers that follow Medicare NCCI.⁵ Modifier -59 is used to unbundle NCCI edits when the procedures are performed on a separate encounter, separate anatomical site (eye), or by a separate practitioner. Consult private payer-specific guidelines to ensure proper application of this modifier.

JW AND JZ MODIFIER

The -JW and -JZ modifiers are used when billing Medicare for certain drugs with pass-through status, utilizing the appropriate HCPCS drug code, and for single-use vials. Ambulatory surgical centers are required to include the -JZ modifier in their reports for all applicable drugs where no amount of medication is discarded from a single dose or single use packaging. This reporting should commence no later than July 1, 2023.⁶

For example, a standard cataract patient elects to also have a placement of Dextenza. The ASC procedure coding would include the appropriate CPT code for the cataract surgery with laterality modifier (66984-RT) listed first followed by the insertion of drug-eluting implant CPT code with laterality (68841-RT). Dextenza is packaged as a single use drug⁷; therefore, the appropriate HCPCS code (J1096) would be listed on the ASC claim form with the modifier -JZ, indicating no medication was discarded or wasted.

SERVICES PERFORMED AT AN ASC

Modifier -SG is no longer required for Medicare and most commercial payers. This modifier was required to be appended to all CPT codes that were performed in an ASC prior to January 1, 2008. ASCs should not use -SG modifier on CPT codes unless specifically directed by the payer.

Understanding modifier rules and payer variations is crucial for accurate billing, coding compliance, and financial stability. Consultation of payer-specific guidelines, available online or through provider representatives, is necessary to ensure compliance and avoid claim denials. By staying informed and implementing proper coding practices, ophthalmologists and ASC owners can optimize reimbursement and maintain financial viability while providing exceptional ophthalmic care. ■

REFERENCES

1. Centers for Medicare and Medicaid Services. “Ambulatory surgical center (ASC) inappropriate use of modifier 50.” March 26, 2018. Updated March 3, 2023. Accessed June 23, 2023. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55895&ver=2&articleStatus=all&sortBy=title&bc=3 
2. Noridian Healthcare Solutions. “Ambulatory Surgical Center Terminated Surgical Procedures Documentation.” Updated October 25, 2022. Accessed June 23, 2023. https://med.noridianmedicare.com/web/jeb/specialties/asc#claim-submission 
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 14 — Ambulatory Surgical Centers. March 24, 2023. Accessed June 23, 2023. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf 
4. First Coast Service Options. “Modifiers applicable to ambulatory surgical centers (ASCs).” Updated March 4, 2022. Accessed June 1, 2023. https://medicare.fcso.com/Ambulatory_surgical_center/0493984.asp 
5. Centers for Medicare and Medicaid Services. Medicare NCCI 2023 Coding Policy Manual — Introduction. January 1, 2023. Accessed June 23, 2023. https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-introduction.pdf 
6. Medicare Learning Network. “Ambulatory Surgical Center Payment System: January 2023 Update.” Centers for Medicare and Medicaid Services. January 17, 2023. Accessed June 23, 2023. https://www.cms.gov/files/document/mm13041-ambulatory-surgical-center-payment-system-january-2023-update.pdf 
7. Dextenza prescribing information. U.S. Food and Drug Administration. Revised June 2019. Accessed June 23, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/208742s001lbl.pdf 

Matthew Baugh, MHA, COT, OCS, OCSR is a coding and reimbursement manager for the American Academy of Ophthalmology in San Francisco. Reach him at mbaugh@aao.org.