Description
Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable both to outpatient hospital departments and to ambulatory surgical centers. Documentation will be reviewed to determine if the billed procedures meets Medicare coverage criteria and applicable coding guidelines for the use of modifiers 73 and 74.
Affected Code(s)
Paid HCPCS with one of the following ICD-10-CM diagnosis codes- Z53, Z53.0, Z53.01, Z53.09, Z53.1, Z53.2, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR §414.40 Coding and Ancillary Policies
8. 42 CFR §419.44 Payment Reductions for Procedures
9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
10. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §10.5- Discounting; §20.6- Use of Modifiers, §20.6.1- Where to Report Modifiers on the Hospital Part B Claim, and §20.6.4- Modifiers 73 and 74
11. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40.4- Payment for Terminated Procedures
12. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §20.3- Use and Acceptance of HCPCS Codes and Modifiers
13. American Medical Association (AMA) Current Procedural Terminology (CPT) Codebook
14. American Medical Association (AMA), Current Procedural Terminology, Appendix A Modifiers
15. American Hospital Association (AHA) International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Codebook
16. American Hospital Association (AHA) Coding Clinic for Healthcare Common Procedural Coding System 2007, Volume 7, Number 1, Page 1- Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS
17. American Hospital Association (AHA) Coding Clinic for Healthcare Common Procedural Coding System 2008, Volume 8, Number 2, Pages 1-4- Special Issue: Modifiers 52, 73, and 74
18. American Hospital Association (AHA) Coding Clinic for HCPCS 2016, Volume 16, Number 1, Page 12- Appropriate Use of Modifiers for Discontinued Services under the OPPS
19. AMA CPT Assistant, September 2003, Page 3- Hospital Outpatient Reporting Part IV: Use of the CPT Modifiers ’52,’ ’58,’ ’59,’ ’73,’ ’74,’ ’76,’ ’77,’ ’78,’ and ‘91’