- Anesthesia Modifiers
- Appropriate Usage of Modifier 99
- Assistants at Surgery at Teaching Hospitals
- Bundled Services Missing Appropriate Modifiers at Time of Initial Claim Submission
- Clarification for Billing Services on Fingers and Toes Using Modifiers F1-F9, FA, TI-T9 and TA vs. Modifier 50
- Correct Usage of Modifier 79 for Multiple Procedures
- Co-Surgery/Team Surgery/Assistant Surgery Modifiers
- Modifier 25
- Modifier 33
- Modifier 51
- Modifier 52 Claim Submission Billing Reminder
- Modifier 59 and the Subset Modifiers XE, XP, XS, XU - Specific Modifiers for Distinct Procedural Services
- Modifier 90 Reference to Outside Laboratory
- Modifiers Used in CMS-1500 Claim Reporting
- Modifier Usage
- Proper Billing of Surgical Comanagement (Modifiers 54 and 55)
- Proper Use of Modifiers 59 and 91
- Reminder for Submission of Modifier 22
- Repeat Procedures - Modifiers 76 and 77
Correct Usage of Modifier 79 for Multiple Procedures
National Government Services Medical Review department has identified widespread problems with the use of modifier 79 for multiple procedures.
The global surgical package was established by CMS to ensure that all components of surgery (including pre and postoperative services) were bundled into one payment.
Modifier 79 (unrelated procedure or service by the same physician during the postoperative period) was established to simplify billing for services provided to a patient during the post-operative period that were unrelated to the original surgical procedure. Prepayment edits were put into place to detect services that were unbundled from the GSP. However, by billing services with modifier 79, they are excluded from those prepayment edits.
The OIG initiated an investigation after receiving allegations that a provider was billing for surgeries that were never performed. The investigation substantiated the allegations and revealed that the provider was billing surgeries every five to six days. To avoid detection, the provider billed the surgeries using the modifier 79. The provider’s abuse of the modifier 79 enabled him to defraud the Medicare Program of a significant amount of dollars.
As such, CMS has expressed concern about the use of modifier 79, as indicated in Change Request 6334. The CMS has instructed contractors to strengthen program safeguards to prevent improper payment for modifier 79.
NGS MR department performed data analysis on the utilization of Modifier 79. The data showed some aberrancy of its usage. For that reason, the Medical Review department may implement appropriate corrective action(s) (e.g., establish prepayment edit, develop pre and postpayment reviews) in the near future.
The modifier 79 should not be reported with the procedure if it’s related to the original procedure or if it’s a staged procedure during the postoperative period. If the service performed is related to the original procedure, it's considered part of the global period, and modifier 79 should not be applied. However, if the related procedure was unplanned following the initial procedure during the postoperative period, modifier 78 should be reported. If the procedure is staged or related to the initial procedure during the postoperative period, modifier 58 should be applied.
Related Content
- Change Request 6344, Modifier 79
- CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40
Revised 9/28/2023