Medical billing mistakes cost paying companies huge sums of
money in excessive workers’ compensation-related expenses every year. Many of
these mistakes are due to coding errors, particularly the misuse of certain
modifiers.
The way medical billing works is that whenever a patient
receives care, every service rendered is documented. There is a pre-defined CPT
(Current Procedural Terminology) code for each service or procedure, and those
are inputted to create a claim that your business is expected to pay. In
certain situations, modifiers (two-digit codes) are added to CPT codes to
identify that a procedure may have been altered by a certain condition.
When modifiers are incorrectly applied (or in some cases, not
applied when they should be), bills are miscalculated, often sticking the payer
with excessive fees they shouldn’t be responsible for paying.
One particular set of modifiers that is commonly
misunderstood and misused includes Modifiers 80, 81, 82 and AS. All of these
modifiers fall under the category of “assistant at surgery.” However, each
modifier is unique and has its own conditions for when they apply.
- Modifier 80 is used when the individual providing the assistant at surgery service is a medical doctor (MD). These services are paid at 20 percent of fee schedule.
- Modifier 81 should be used to identify “minimal” assistant surgeon services. While there is often confusion between Modifier 80 and Modifier 81 due to a lack of definitive guidelines, Modifier 81 is typically used when the individual providing the minimal assistant surgery service is an RN/CSA. These services are paid at 10 percent of fee schedule.
- Modifier 82 is used when the individual providing the assistant at surgery service is an MD and there was not a qualified resident surgeon available. Only teaching hospitals may submit this modifier. These services are paid at 20 percent of fee schedule.
- Modifier AS is used when the individual providing the assistant at surgery services is a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist. These services are paid based upon jurisdictional fee schedule guidelines—typically between 10-17% of fee schedule
Here’s an example of how correct billing using these
modifiers might look.
- Primary surgeon bills with no modifier – paid at 100 percent of fee schedule
- MD assistant surgeon bills with Modifier 80 – paid at 20 percent of fee schedule
- RN assistant surgeon bills with Modifier 81 – paid at 10 percent of fee schedule
- PA-C assistant surgeon bills with Modifier AS – paid as indicated per jurisdictional fee schedule rates (10-17%)
It’s also important to note that these assistant at surgery
services should only be paid if NCCI (National Correct Coding Initiative)
allows the use of an assistant for the particular procedure being performed.
With so many distinctions between the modifiers and so many
guidelines determining when each modifier can be used, it’s always a good idea
to have your medical bills professionally audited to ensure there’s no mistakes
or extraneous fees.
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