Modifiers

Modifier -24 Unrelated Evaluation and Management Service by the Same Physician during a
Postoperative Period
Modifier -25 Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician on the Same Day of the Procedure or Other Service
Modifier -26 Professional Component

Modifier TC Technical component only - Use to indicate the technical part of a diagnostic procedure
performed.

Modifier -51 Multiple Procedures

Modifier -52 Reduced Services

Modifier -54 Surgical Care Only

Modifier -57 Decision for Surgery

Modifier -59 Distinct Procedural Service

Modifier -73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure prior to the
Administration of Anesthesia
Modifier -74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure after
Administration of Anesthesia
Modifier -76 Repeat Procedure by Same Physician
Modifier -77 Repeat Procedure by Another Physician
Modifier -78 Return to the Operating Room for a Related Procedure During the Postoperative Period
Modifier -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Modifier -80 Assistant Surgeon
Modifier -81 Minimum Assistant Surgeon
Modifier -82 Assistant Surgeon (when qualified resident surgeon not available)
Modifier -90 Reference (Outside) Laboratory
Modifier -91 Repeat Clinical Diagnostic Laboratory Test
Modifier -92 Alternative Laboratory Platform Testing

Modifier GC This service has been performed in part by a resident under the direction of a teaching
physician.

Modifier LT Left Side - Used to identify procedures performed on the left side of the body.

Modifier RT Right Side - Used to identify procedures performed on the right side of the body.

Modifier QC Single channel monitoring.

Modifier QW CLIA Waived Test - Effective October 1, 1996, all new waived tests are being assigned a
CPT code (in lieu of a temporary five-digit G- or Q-code)

Modifier AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-
surgery, non-team member.
QUESTIONS & ANSWERS

Q: What is the difference between LCDs and NCDs?

A. Local coverage determinations (LCDs) for a specific jurisdiction are developed by the Medicare
Administrative Contractor (MAC) assigned to that jurisdiction. First Coast Service Options Inc. is the MAC
for Florida, Puerto Rico, and the U.S. Virgin Islands. Although the majority of coverage determinations
are local, in certain cases, Medicare may develop a national coverage determination (NCD) that is
applicable to all jurisdictions.

CO-50 Not deemed as medical necessity k denial mei most authentic source to check correct dx is
the corresponding LCD for that code

Q: How many digits in PTAN?

A: The provider number/PTAN is usually six digits in length, and assigned based on the type and location
of the provider.

Q: How many digits in NPI?

A. 10

Q: How many digits in Tax ID?

A. 9

Q: What is annual deductible of Medicare?

A. $ 198 of 2020 & $185 for 2019

Q: What is copay of Medicare?

A. There is no copay of Medicare

Q: How many digit in taxonomy code and what is it used for?

A. Medical billing taxonomy codes are a 10 digit alphanumeric character set used to classify health
care organizations in accordance to the primary services they provide.

Q: Why medical necessity denial come and what is our action on it?

A. DX and procedure code not matched

Q: What is CLIA ?

A. The Clinical Laboratory Improvement Amendments (CLIA) regulate laboratory testing and require
clinical laboratories to be certified by the Center for Medicare and Medicaid Services (CMS) before they
can accept human samples for diagnostic testing

Q: What is CLIA wave test?

A. The test in which CLIA certification not required example: X-Press Drug Test 80305 QW

Q: Tell X-ray related CPT?

A. Abdomen 1-view74000

Q: What are E&M code?

A. E/M stands for “evaluation and management”. E/M coding is the process by which physician-patient
encounters are translated into five digit CPT codes to facilitate billing.

Q: What CPT goes for initial visit and subsequent?

A. 99201-99205 for New 99211-99215 for subsequent

Q: What is difference between initial visit and subsequent visit?

A. Initial encounter. Use this when the physician actively treats the condition during the initial
encounter (e.g., surgical treatment, ED encounter, evaluation by new physician). Subsequent
encounter. Use this for encounters after the physician performs the initial treatment, but the
patient continues to receive care during the healing or recovery phase (e.g., cast change/removal,
removal of fixation, medication adjustment).
Q: Corrected claim kis code k sath jata ha?

A. With code 7 in block 22 of HCFA

Q: Tell any lab test CPt?

A. CPT Code range (80047-89398) for pathology

Q: What is NDC and how many digits are in it?

A. NATIONAL DRUG CODE Each listed drug product is assigned a unique 10-digit, 3-segment number.
This number, known as the NDC, identifies the labeler, product, and trade package size. The first
segment, the labeler code, is assigned by the FDA.

Q: What should we do if timely filing denied come?

A. APPEAL with proof?

Q: What is your course of action on non-covered services denied reason?

A. if claim denied at patient end so billed to patient and if on provider End or not Eligible then need
provider consent to adjust

Q: To which insurances corrected claim was sent?

A. Corrected claim send to all insurances except Medicare and Medicaid (in dono ko new claim jata ha)

Q: If DX code issue come what will you do?

A. Discuss with coding team and also take consent of provider

Q: What is different between rejections and denied?

A. rejection come from clearing house or insurance as claim not entered to insurance system due to
data mismatched error & denial comes after insurance processing

Q: If denied come of maximum benefit reach what will you do?

A, verify number of unit/days on CPT and also verify duplicate claim and if these error not exist then
make a call to insurance to check if this claim paid to another tax iD

Q: What is inclusive denial and what is action on it?

A. Add modifier with denied CPT like 59

Q: What is bundled denial and what is action on it?

A, Add appropriate modifier

Q: If provider is angry and discuss your aging plan what is your plan for his total aging?

A.

Q: What is NCCI edits?

A. National Correct Coding Initiative Edits

The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding
methodologies and to control improper coding leading to inappropriate payment in Part B claims. ... The
purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are
reported.

HCFA BOX

21 DX codes A- L

22 Resubmission code & original claim #

23 Prior Authorization

24A DOS , 24B POS, 24C Emergency Indicator, 24D CPT/HCPCS, 24E Dx pointer setting, 24F charges, 24G
Days/units , 24H EPSDT family plan 24i ID Qualifier .24J Rendering provider ID/NPI

25 Tax ID

26 Patient account number

27 accept assignment

28 Total charge

29 Amount paid

30 Balance Due

31 Signature of Physician or Supplier Including Degrees Credentials

32 Service Facility Location Information

33 Billing Provider Info & Phone #

FORMATES

837 contain claim information and are sent by healthcare providers (doctors, hospitals, etc) to payers
(health insurance companies)

835 ERA contain payment (remittance) information and are sent by the payors to the providers to
provide information about the healthcare services being paid for.

276 Transaction is used to inquire about the current status of a specified claim or claims

277 Transaction in response to that inquiry.

271 Transaction is the EDI function that responds eligibility and benefit information of the patient.

270 transaction is the EDI function that requests eligibility and benefit information from the Insurance
Company of the patient. It is set to receive care from a Provider of Service.