Feb

17

CMS increases its scrutiny of modifier -79 for multiple procedures

By Medicare Weekly Update

By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro, Inc.

Last week, CMS published a One Time Notification related to modifier -79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period) and the global surgical package (GSP). The GSP is a feature of Medicare’s payment system for physicians and so at first blush this transmittal would appear not to apply to hospital providers. However, CMS’ business requirements apply to both carriers (who traditionally process physician claims) and fiscal Intermediaries (who traditionally process hospital claims), indicating that CMS is concerned about modifier -79 usage in both settings.  

For hospitals, even though the GSP does not apply, modifier -79 has a payment impact on the multiple procedure reduction. It is used to override the multiple procedure reduction when procedures are provided in separate sessions and therefore not subject to the multiple procedure reduction policy. The result of applying modifier 79 is that both procedures will be paid at 100% of the payment rate, rather than being subject to the multiple procedure reduction that reduces all but the highest-paying procedure by 50%.  

The instruction requires contractors to review modifier -79 claims and take appropriate action such as pre-payment edits or post-payment reviews. The instruction is being made as a result of an Office of Inspector General report on misuse of modifier -79. While the finding cited a particular physician’s misuse of modifier -79, modifier -79 was included in the OIG Work Plan for hospitals in 2006 and 2007.  

Hospitals should review their use of modifier -79, ensuring that coders have been provided appropriate education on the use of modifier -79 and its impact on both the NCCI edits and the multiple procedure reduction. Proper application of modifier -79 requires that the coder understand not only the coding implications related to the NCCI, but also the payment implications related to the multiple procedure reduction.