MODIFIER EXAMPLES

1: A physician providing diagnostic or therapeutic radiology services, ultrasound, or nuclear medicine services in a hospital would use modifier -26 to report the professional component, as follows:

 73090-26 = Professional component only for an x-ray of the forearm 

2: Two surgeons, usually with different skills, may be required to manage a specific surgical problem. The modifier -62 would be applicable. Modifier -62 would be appropriate only when both surgeons are reporting the same code number and descriptor. For instance, a neurological surgeon and an otolaryngologist are working as cosurgeons in performing transsphenoidal excision of a pituitary neoplasm. The first surgeon would report: 

61548-62 = Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic + two surgeons modifier AND the second surgeon would report: 

61548-62 = Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic + two surgeons modifier 

ANESTHESIA GROUND RULES

GENERAL: All anesthesia values are determined by taking the BASIC UNIT VALUE, which is related to the complexity of the service, and adding MODIFYING UNITS (if any), and TIME UNITS. The fee for a particular procedure or service in this section is determined by multiplying the listed "Basic Unit Value" by the conversion factor that is applicable to this section. . 

The values contained within this section apply when the anesthesia care is provided by or under the medical supervision of qualified physician. This anesthesia care may include but is not limited to general, regional, monitored anesthesia care, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal. For anesthesia care provided by nurse anesthetists, billing for independent unsupervised services, payment will be limited to 85% of the maximum allowable fee associated with the CPT code submitted. 

PROCEDURES/SERVICES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE

Some procedures/services are not accompanied by allowable fees. Procedures/services denoted "by report" (BR) in the maximum fee column are too unusual or variable in the nature of their performance, too new, or too infrequently performed to permit the assignment of a maximum fee. Fees for such procedures/services need to be justified "by report." The report should contain sufficient supportive information to permit proper identification. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the time, the skill, and equipment necessary, etc. For any procedure/service where the maximum fee is "BR," the health care provider shall establish a charge that is consistent with other maximum fees shown in the Schedule. The insurance carrier or selfinsured employer should review all submitted "BR" amounts to assure that an excessive charge for services provided is not occurring. Note also that for any procedures/services not listed within this Fee Schedule, the associated charge(s) will need to be substantiated "by report" (BR).

DEFINITIONS 

New Patient: One who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. 

Established Patient: One who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available. 

Note that no distinction is made between new and established patients in the emergency department. E / M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.