Providers often struggle with modifiers–even those they’ve had available to report for many years–due to the unique scenarios they face at their facilities, staffing changes, and/or unclear or lacking authoritative guidance.
Starting January 1, 2016, CMS will require three new modifiers for providers to report. The good news is that it’s pretty clear when they must be reported, but the bad news is that it will take some time to determine the best way for each provider to operationalize them before the new year begins.
Modifier -CT
As a result of the Protecting Access to Medicare Act of 2014, CMS is introducing modifier -CT (computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR-29-2013 standard) effective January 1, 2016.
Providers will need to append this modifier to a predetermined list of CPT®/HCPCS codes for CT scans when the services are furnished on equipment that does not adhere to NEMA standard XR-29-2013. Those codes are:
- 70450-70498
- 71250-71275
- 72125-72133
- 72191-72194
- 73200-73206
- 73700-73706
- 74150-74178
- 74261-74263
- 75571-75574
When these codes are reported with the modifier on a claim to be paid separately (i.e., not packaged into a composite APC or comprehensive APC [C-APC]), CMS will impose a 5% payment reduction in 2016 and a 15% payment reduction beginning in 2017. This payment reduction applies under both the Medicare Physician Fee Schedule (MPFS) and the OPPS.
The first step providers need to take is to talk with staff in the radiology department to determine whether the equipment in their facility is compliant with the NEMA standard. If the equipment is compliant, that’s great news, and those providers will not need to worry about using modifier -CT in 2016 and beyond, nor will they face any payment reductions for their CT services. If providers learn that some or all of their equipment is not compliant, then they should contact their vendors immediately to see if they can get compliant as soon as possible. If that’s not possible, then they will need to immediately determine how to operationalize reporting modifier -CT.
Providers need to know how many noncompliant machines they have and where they’re located. If a facility only has one noncompliant machine, then hardcoding modifier -CT with the related CPT codes may be the simplest solution until the machine is made compliant. If providers have multiple machines in the same or different locations and only some are compliant, then hardcoding may not be a good option.
Providers do not want to over-report modifier -CT and take a payment hit if it’s not necessary; similarly, they do not want to risk under-reporting modifier -CT since they could get overpaid.
Getting the reporting 100% correct is critical, since this modifier impacts both revenue and compliance. The key to getting the reporting correct is taking stock of equipment and internal processes. The best thing providers can do is get their machines or equipment NEMA compliant as soon as possible.
For more information on requirements for reporting modifier -CT, see CMS Transmittal 3402.
Modifier -CP
Modifier -CP (adjunctive service related to a procedure assigned to a C-APC procedure, but reported on a different claim), also effective January 1, 2016, is a data collection modifier.
The data collected by CMS in 2016 and 2017 is likely to inform future reimbursement for the stereotactic radiosurgery (SRS) C-APC, so accurate and consistent reporting across providers now will be important for future reimbursement. But it will not impact reimbursement in 2016, unlike modifier -CT, which will have payment implications starting January 1.
CMS will require modifier -CP when adjunctive services are reported on a separate claim for status indicator J1 stereotactic radiosurgery (SRS) services reported with the following codes:
- 77371, radiation treatment delivery, SRS, complete course of treatment of cranial lesion(s) consisting of one session; multi-source Cobalt 60-based
- 77372, radiation treatment delivery, SRS, complete course of treatment of cranial lesion(s) consisting of one session; linear accelerator-based
In the 2016 OPPS final rule, CMS says the modifier will be required when related or adjunctive services are provided up to 30 days before the SRS service and when provided on a different claim from the SRS.
While this is going to be operationally challenging and has already raised many questions, one thing providers can be grateful for and to consider a win is that CMS only finalized this modifier for use with related/adjunctive services for SRS and not for reporting related/adjunctive services for all C-APCs as originally proposed. Establishing the modifier only for SRS clearly shows that CMS heard commenter concerns about the operational difficulties with implementing it for all C-APCs.
Therefore, starting with requiring modifier -CP for only SRS allows CMS and providers to essentially pilot test this on a limited set of services, where the industry at least has an idea of many of the related/adjunctive services that could be billed on a separate claim.
Providers will again need to determine how best to operationalize the application of this modifier, which is likely going to involve individuals in many departments coming together to discuss the coding and billing processes in place today and the new ones that may be required in the future.
In the final rule, CMS unbundled the services shown by the list of codes below from the SRS C-APC payment rate, which means separate payment will be provided for these services when billed either on the same or separate claim from the SRS service in 2016 and 2017. Providers should ensure their chargemasters are updated for these codes:
- CT localization (HCPCS codes 77011 and 77014)
- MRI imaging (HCPCS codes 70551, 70552, and 70553)
- Clinical treatment planning (HCPCS codes 77280, 77285, 77290, and 77295)
- Physics consultation (HCPCS code 77336)
These codes are a good place for providers to start when trying to think about all of the different services patients would receive as a related or adjunctive service to SRS. Just keep in mind that there may be other services considered related or adjunctive to SRS provided 30 days prior on a different claim that would need to be reported with the modifier as well.
Operationalizing this modifier poses a unique challenge since it needs to be appended to services that are related to a service that hasn’t occurred yet (i.e., the SRS service). If providers don’t know that SRS has been ordered, scheduled, or is in the patient’s near future (within 30 days), then how will they know to append modifier -CP to services that occur days or weeks before SRS?
Providers should work with their radiation oncology department to determine how best to identify SRS patients and to monitor the services they are receiving over a period of time. One of the easiest ways, though not the most popular may be to hold claims until all services have been rendered so that one can definitively work through appending modifier -CP to all related services reported on separate claims.
There is no one-size-fits-all method to applying modifier -CP, so each provider will need to find the simplest, most accurate method to use this new modifier.
One thing providers can do right now is run reports to see what services have typically been reported 30 days prior to 77371 and 77372 for their SRS patients, and when they’ve been billed, in order to determine what services, in addition to the ones CMS has unbundled, might require the new modifier.
The danger with not reporting modifier -CP is that CMS will not have a sense of what costs from other services need to be built into the future SRS C-APC rate. CMS may simply use the data it has, while also eliminating separate payment for all of the services it has unbundled. The bottom line is that providers may see significant payment decreases in the future for SRS when only a single C-APC is assigned and separate payments for "related/adjunctive" services are eliminated if the C-APC is not reflective of all of the different types of related/adjunctive services provided to patients.
In the final rule, CMS says that it will issue further sub-regulatory guidance on using the modifier prior to January 1, 2016, to address commenters’ technical questions. Providers should be on the lookout for this information to ensure they begin reporting the new modifier properly when 2016 begins.
Modifier -PO
Providers are likely familiar with modifier -PO (services, procedures, and/or surgeries furnished at off-campus, provider-based outpatient departments) by now since its reporting has been voluntary throughout 2015 and becomes mandatory beginning January 1, 2016.
We’ve known about this modifier for some time, but many hoped it would remain voluntary for a longer period of time or go away altogether. No such luck.
Hopefully by now, providers have evaluated and catalogued all of their provider-based departments/settings to determine which are off-campus versus on-campus, as modifier -PO will be required to be reported on all OPPS-payable services provided in off-campus provider-based locations.
This includes packaged services, such as packaged labs, when provided in off-campus provider-based locations. Knowing whether to even worry about using this modifier and how many locations/sites to use it for is step one.
Step two is determining how to operationalize the use of this modifier. This modifier, like modifier -CP, does not have immediate payment implications, but it could in the future. Nevertheless, accurate and complete reporting is something the industry can expect CMS to monitor, especially in light of the budget bill Congress passed in November 2015. That bill restricts OPPS payments to off-campus provider-based locations starting in 2017 based on whether they were already designated as off-campus provider-based locations by November 1, 2015.
The inclusion of this provision in the budget bill came as a surprise to many given that it seemed CMS’ original plan was to collect data on what services are provided in on- versus off-campus provider-based departments and to examine payment difference among services in order to propose site-neutral payment policies in the future.
The budget bill seems to have sped up the process of clamping down on the overall issue of what CMS believes is overpaying certain types of services when rendered in provider-based departments versus free-standing sites. The issue of site neutrality and what was finalized in the budget bill are separate but clearly related items, as both are meant to address payment system differentials based on site/location.
By not allowing new off-campus provider-based locations to be paid under OPPS rates starting in 2017, Congress has drawn a hard line in the sand. But providers can likely expect to see the issue of site-neutral payments surface again once CMS has collected data on modifier ?PO and place of service codes 19 and 22 it introduced for physician reporting.
Based on what we know now, providers will still be required to report modifier -PO starting January 1, 2016, which means they need to determine the best way to operationalize this modifier. Hardcoding is again an option, and perhaps one that is easy to implement by using location codes and setting up the charge description master with duplicate lines for services provided in on- and off-campus locations. Another option is to use billing system edits or claims processing/editing logic to identify locations and have the modifier appended.
Providers should talk with their billing system vendors now to see if they can find a way to automate the use of modifier -PO, such as using location codes, since 100% of the services on the claims from off-campus provider-based locations will require the modifier.
A third option is to append the modifier manually, though this seems the least efficient method. However, it may be an option depending on the number of locations a provider has, system capabilities, and other considerations.
Like the other modifiers discussed, appending modifier -PO doesn’t have a one-size-fits-all solution. The best method will be determined by the number of off-campus locations, billing systems, volume, staffing, etc.
The most important factor to consider with any of these modifiers is the ease of application and accuracy. Providers want to streamline the process and automate as much as possible, but this must be balanced with accurate modifier use. Testing and internal auditing of these modifiers will be important to include in 2016 internal auditing plans.
Editor’s note: Shah is president and founder of Nimitt Consulting. This article was originally published in Briefings on APCs. Email your questions to editor Steven Andrews at sandrews@hcpro.com.