When you think of the Medicare Physician Fee Schedule (MPFS), fees might be the first word that comes to mind. But modifiers should be a close second. Here’s how you can use the MPFS to improve your modifier accuracy for Medicare claims.
Start here: To read about the MPFS bilateral indicator and modifier 50, read our blog post on bringing in correct bilateral pay.
See If Payment for More Than One Surgeon Is Allowed
If you open the MPFS file with RVUs from the Medicare site, you’ll see columns for ASST SURG, CO-SURG, and TEAM SURG. The indicators in those columns will let you know Medicare’s stance on coding and payment for multiple providers performing a procedure. (If you use an online coding package for your MPFS data, make sure this sort of modifier information is included and updated quarterly.)
Before using modifier 62 (Two surgeons), check the CO-SURG column, which applies to surgeons in different specialties. For team surgeons (modifier 66, Surgical team), check the TEAM SURG column. The ASST SURG column gives you information about assistant surgeons (such as modifier 80, Assistant surgeon).
The indicator will let you know whether payment for the additional provider is permitted, not permitted, or possibly permitted if documentation supports medical necessity.
Knowing whether you may use the modifiers is important both for coding accuracy and for payment. For instance, with modifier 62, the fee schedule amount for each co-surgeon is 62.5 percent of the global surgery fee schedule amount.
Check Rows and Columns for 26/TC
Medicare splits some codes into professional and technical components. This simplifies reporting and payment for services like radiologic exams where the entity performing the test and the interpreting provider may be different.
To report only the professional component, which is essentially the work of the physician, append modifier 26 (Professional component). Be careful not to use modifier PC (Wrong surgery or other invasive procedure on patient) for professional component.
For the technical component, use modifier TC (Technical component). The technical component covers costs like paying techs, paying for equipment, and paying for the space used.
Column: To determine whether your code has a professional/technical split, check the MPFS PCTC IND column. There are 10 indicators, so don’t make assumptions when it comes to these codes. Make sure you know where to find the full modifier indicator definitions when you need them. (Online fee schedule tools may include indicator definitions with the fee information for a code so you don’t have to hunt it down each time you need it.)
Row: You also can get a clue about a code’s PCTC status from the rows on the MPFS RVU spreadsheet. Watch for codes that have one row for a code, one row for the code with TC, and one row for a code with 26. This setup lets you see the MPFS data, such as RVUs and indicators, specific to either the global code (called that because it includes both the professional and technical components) or the particular component.
Tip: If you’re checking out rows, you may notice that some colonoscopy codes also have a row for 53 (Discontinued procedure). That row sets the MPFS RVUs so contractors pay a consistent amount for those codes with modifier 53 appended.
Use Mod 51 Column for Knowledge
The MULT PROC column is tied to modifier 51 (Multiple procedures). But remember that Medicare and many other payers instruct you not to use modifier 51 because the payer will apply the fee reduction rules based on the codes reported and their MPFS indicators.
So instead of using this column to decide whether to add modifier 51, use the column to get an idea of what payment will look like. For instance, if the indicator for the code is 2, apply this definition:
- 2 = Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, MACs rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report). MACs base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
What About You?
Do you check the MPFS indicators before applying these modifiers?