Telemedicine Modifier 93 Updates 2022

The modifier 93 (Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System).

Modifier 93 is a new audio-only telemedicine code that is effective on Jan. 1, 2022. Modifier 93 describes services that are provided via telephone or other real-time interactive audio-only telecommunications systems.

This modifier is appropriate only if the real-time interaction occurs between a physician/other qualified health care professional and a patient who is located at a distant site.

When using this modifier 93, the communication during the audio-only service must be of an amount or nature that meets the same key components and/or requirements of face-to-face interaction.

Addition of Appendix T

This appendix is a listing of CPT codes that may be used for reporting audio-only services when appended with Modifier 93. Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio. The codes listed in Appendix T will be identified with an audio speaker symbol in the 2023 code set. The list of codes contained in the appendix, used with Modifier 93, is effective April 1, 2022.

The below summary of CPT codes that may be used for reporting audio only services when appended with Modifier 93.

The Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio. The codes listed below are identified with the audio symbol.

90785 Interactive complexity (List separately in addition to the code for primary procedure)

 

90791 Psychiatric diagnostic evaluation

 

90792 Psychiatric diagnostic evaluation with medical services

 

90832 Psychotherapy, 30 minutes with patient

 

90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

 

90834 Psychotherapy, 45 minutes with patient

 

90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

 

90837 Psychotherapy, 60 minutes with patient

 

90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

 

90839 Psychotherapy for crisis; first 60 minutes

 

90840 Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)

 

90845 Psychoanalysis

 

90846 Family psychotherapy (without the patient present), 50 minutes

 

90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes

 

92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual

 

92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals

 

92521 Evaluation of speech fluency (eg, stuttering, cluttering)

 

92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)

 

92523 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)

 

92524 Behavioral and qualitative analysis of voice and resonance

 

96040 Medical genetics and genetic counseling services, each 30 minutes face to face with patient/family

 

96110 Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

 

96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face to face time with the patient and time interpreting test results and preparing the report; first hour

 

96160 Administration of patient focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument

 

96161 Administration of caregiver focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

 

97802 Medical nutrition therapy; initial assessment and intervention, individual, face to face with the patient, each 15 minutes

 

97803 Medical nutrition therapy; reassessment and intervention, individual, face to face with the patient, each 15 minutes

 

97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes

 

99354 Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215])

 

99355 Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; each additional 30 minutes (List separately in addition to code for prolonged service)

 

99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and Management service)

 

99357 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service)

 

99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

 

99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

 

99408 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

 

99409 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes

 

99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face to face with the patient, family member(s), and/or surrogate

 

99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Documentation

The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.

Update for COVID -19 CPT 87637

The Modifier QW is defined as a Clinical Laboratory Improvement Amendment (CLIA) waived test and it is used to identify waived tests and would be submitted in the first modifier field.

The modifier QW is accepted by CMS for CPT 87637 and effective from date October 06,2020 and the implementation date July 06, 2021.

Also, the modifier QW allowed for HCPCS code 0240U & 0241U

87637 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique

0240U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected

0241U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected

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Additional Information About Modifiers

Sequencing of modifiers 

How can that be if the modifiers used were accurate? 

There is an order to reporting modifiers and there are three categories that modifier usage fall under: 

1. Pricing 

• Pricing modifiers are always sequenced “before” payment modifiers and/or location modifiers.  
• The only exception to this rule is when a global surgery package is involved. 
• For example, you would code modifier 58 first and modifier 82 second in a global surgery. 
• A few examples of pricing modifiers are: 22, 26, 50, 52, 53, 62, 80, and P1-P6.  

2. Payment  

• Payment modifiers alert the insurance carrier that there is a special situation within the claim 
• Some examples of payment modifiers would be: 24, 25, 51, 57, 58, 59, 76, and 78. 

3. Location 

• Examples of location modifiers are: E1-E4, FA, F1-F9, LC, LD, LT, RT, RC, TA, and T1-T9. 

The general order of sequencing modifiers is (1) pricing (2) payment (3) location. Location modifiers, in all coding situations, are coded “last”. 

If you code two pricing modifiers that include either a professional or technical component (26 or TC), always use the 26 or TC first, followed by the second pricing modifier. 

If you have two payment modifiers, for example 51 and 59, enter 59 first and 51 second. If 51 and 78 are the required modifiers, you would enter 78 in the first position. 

Additional Information 

000 = Endoscopic or minor procedure with related preoperative and postoperative relative value units on the day of the procedure only, included in the fee schedule payment amount 

010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative values during a 10-day postoperative period included in the fee schedule amount 

090 = Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule payment amount 

MMM = Maternity codes. The usual global period does not apply. 

XXX = Global concept does not apply 

YYY = Palmetto GBA will determine whether the global concept applies and establish a postoperative period, if appropriate 

ZZZ = Code is related to another service ("add-on" code) and is always included in the global period of the other service 

Check Modifier  78 & 79

Modifier 78 and 79

Modifier 78 

“Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period 

Modifier 79

“Unrelated procedure or service by the same physician during a post-operative 

Example - Modifier 78 

The Dual chamber Pacemaker (CPT 33208) was implanted on Dec 26th and during the post-operative periods, the patients feel uncomfortable due to pain, hence the provider examined and confirmed the Atrial lead and or Ventricular lead is dislodged, hence provider performed “Repositioning of right atrial or right ventricular lead” on Jan 10th.  

For mentioned above scenarios, the claim must be submitted with modifier 78, since this procedure performed within 90 days. CPT 33215 – 78 

Example - Modifier 79 

The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.  

Provider performs right toe amputation on May 24, 2015 and a left foot amputation On June 25, 2015, surgery was medically necessary within this 90-day global period 

• 5/24/15 Amputation big toe, RT  28820 TA 
• 6/25/15 Amputation foot, LT  28800 79 

 

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Usage of Modifier 24 and 59

Modifier 24 

An Unrelated evaluation and management service performed by the same physician or other qualified health care professional during a post-operative period use modifier 24 for E/M Services. (Never to a procedure) 

Modifier 24 is applied to two code sets, 

• E/M (Evaluation and management) services (99201-99499). 
• General ophthalmological services (92002-92014), which are eye examination codes. 

Appropriate Use of Modifier 24 

• An unrelated E/M service is performed beginning the day after the procedure, by the same physician, during the 10 or 90-day post-operative period.  
• Documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.
• Unrelated critical care performed by the same physician during the post-operative period. 

Inappropriate Use 

Do not use Modifier 24 when, 

• The E/M is for a surgical complication or infection. This treatment is part of the surgery package. 
• The service is removal of sutures or other wound treatment. This treatment is part of the surgery package. 
• The surgeon admits a patient to a skilled nursing facility for a condition related to the surgery. 
• The medical record documentation clearly indicates the E/M is related to the surgery. 
• Outside of the post-op period of a procedure. 
• Services are rendered on the same day as the procedure 
• Reporting exams performed for routine postoperative care. 
• Reporting surgical procedures, labs, x-rays, or supply codes. 

Example 1 

A Cardiologist was implanted Pacemaker Implantation on Dec. 26th due to complete Heart Block, and the patient returns with Chest pain and diagnosed as angina on Jan. 10th.  

The Jan. 10th visit is separately reportable with appropriate level of service codes with modifier 24, since it’s unrelated to the original procedure performed Dec 26th.  

Modifier 59 – X (E, P, S, U) 

“Distinct Procedural Service” - Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. 

The Centers for Medicare & Medicaid Services (CMS) established four (4) new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported. 

XE – “Separate encounter" A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service. 

XS – “Separate Structure" A service that is distinct because it was performed on a separate organ/structure.

XP – “Separate Practitioner" A service that is distinct because it was performed by a different practitioner.

XU – “Unusual Non-Overlapping Service", the use of a service that is distinct because it does not overlap usual components of the main service.

• Modifier 59 should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes.
• The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. 
• Modifier 59 should not be appended to an E/M service. 

Examples: 

Modifier XU 

• If Cardiac Cath (93454 to 93461) & PCI (92920 to 92943) procedure performed together during the same visit. We can bill with modifier XU for Cardiac Cath Procedures (column 2 codes). 

Modifier XE 

• If the mentioned above procedures are performed in two different encounters, the claim must be billed with modifier XE for Cardiac Cath CPT codes. 

Modifier XP 

• For mentioned above procedures are performed two different providers’, bill the claim with modifier XP. 

Modifier XS 

• For same procedure performed in two different location and or anatomical site we can use modifier XS for same CPT code if there are no anatomical site modifiers applicable, (Like RT & LT) 
• Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550- XS). 

Note: Medicaid & Medicaid HMO’s would not be accepted Anatomical site modifiers and or HCPCS modifier, so please use modifier 59 instead of X (E, P, S, U) and or not required HCPCS modifier, like RT, LT, RC, LC, LD and etc...) 

Modifier Indicator: 

• 0: not allowed (ie, modifier -59 is not allowed under any circumstances; the code pair will not be paid separately); 
• 1: allowed (ie, coders may be able to append modifier -59 to differentiate between services provided; separate payment will be allowed); or 
• 9: not applicable (ie, no modifier is necessary, as the edit is inactive as of the posted date; services may be separately billable). 
  

 

Return to check modifier 25 & 57

Usage of Modifier 25 vs 57

Modifier 25 

 

Significant, separately identifiable evaluation and management [E/M] service by the same physician or Other Qualified Health Care Professional on the same day of the service 

Modifier 25 is appended to an E&M service, when performed 0 days and or 10 days global period - (never to a procedure) 

 

Example 1:  

 

A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed on same day by the same physician. 

The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure. 

The modifier stops the bundling of the E/M visit into the procedure. When reviewing the physician’s documentation, the carrier should be able to determine that both the E/M and the procedure were medically necessary. As always, the documentation has to support the claim that sends to the carrier if required. 

 

Examples of when Not to Use Modifier 25 

 

Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery. 

Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done). 

Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed. 

Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E/M service included. See example #2. 

Patient came in for a scheduled procedure only – Do not code E/M service. 

 

Modifier 57 

 

Modifier 57 is an “Decision for Surgery”, Modifier 57 should only be appended to E/M codes. 

Difference between for modifier 25 vs modifier 57, 

• Modifier 25 - Use modifier -25 on an E/M service provided on the same day as a minor procedure 
• Modifier 57 - Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery 

Major surgery includes all surgical procedures assigned a 90-day global surgery period. 

Append, only to the E/M procedure code, where the decision to perform surgery is made the day of or day before a major surgery during an E/M service. 

 

Inappropriate Uses 

 

• Appending to a surgical procedure code.
• Appending to an E/M procedure code performed the same day as a minor surgery. 
• When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure.
• Do not report on the day of surgery for a pre-planned or pre-scheduled surgery. 
• Do not report on the day of surgery if the surgical procedure indicates performance in multiple sessions or stages. 

 

Guidelines: 

 

• Global period includes, 
• Day before surgery 
• Day of the surgery; and 
• Number of days following the surgery 

E/M service resulting in initial decision to perform major surgery is furnished during post-operative period of another unrelated procedure, then the E/M service must be billed with both the 24 and 57 modifiers 

Note: A major surgery has a 90-day post-operative period and a minor surgery has either a zero or a 10-day post-operative period. 

 

Example 1 

 

A surgeon seeing the patient in the emergency department, then performs CPT code 65285 repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue on the same day. Since this surgical code has a 90-day global period, the correct way to bill the E/M for separate, appropriate payment is 99284-57 emergency department visit for the evaluation and management of a patient; 65285. 

 

Example 2 

 

The patient came for ED and presents with Chest Pain, Lightheadedness and palpitation on Dec 26th. And called as Cardiology consult, He is evaluated the patient and diagnosed as complete Heart Block, Coronary Artery disease. Due to the severity of the patient’s condition, the decision was made to implant Dual Chamber permanent pacemaker on tomorrow, after diagnostic testing was completed on the same date. The patient was admitted to the hospital on the same day; the claim for hospital admission was submitted with CPT code 99221 and consult document supported to bill CPT 99255. 

• Admit – 99221 
• Consult – 99255 - 57 
• Pacemaker - 33208 

Return to check modifier 24 & 59