Stream: implementers
Topic: Procedure & CPT modifier
nicola (RIO/SS) (Dec 12 2017 at 19:53):
Hello
Where and how to put CPT modifier code in Procedure?
Grahame Grieve (Dec 12 2017 at 20:07):
what's a CPT modifier code?
nicola (RIO/SS) (Dec 12 2017 at 20:08):
https://www.sccma-mcms.org/portals/19/assets/docs/modifier-reference-guide.pdf
nicola (RIO/SS) (Dec 12 2017 at 20:10):
Now i put it like {rt: Procedure, code: {coding: [{system: cpt-url, value: ...}, {system: cpt-modifier-url, value: ...}]
Jose Costa Teixeira (Dec 12 2017 at 20:10):
Billing stuff?
nicola (RIO/SS) (Dec 12 2017 at 20:10):
Yes
Jose Costa Teixeira (Dec 12 2017 at 20:11):
Procedure is an event. which means that you are putting a code in every instance of procedure, for each patient, right?
Jose Costa Teixeira (Dec 12 2017 at 20:12):
you are not defining "this kind of procedure has this CPT code in this hospital", right?
nicola (RIO/SS) (Dec 12 2017 at 20:13):
We are getting external HL7 DFT/P03 and mapping FT1 segment to Procedure => next step is generate Claim
Jose Costa Teixeira (Dec 12 2017 at 20:14):
ok, just to make sure. it's different to assign a code to a transaction (what you are doing) and assigning codes for the procedure definition.
nicola (RIO/SS) (Dec 12 2017 at 20:15):
Yes, we are describing concrete procedures for concrete patient
nicola (RIO/SS) (Dec 12 2017 at 20:15):
We model price list using HealthcareService
Jose Costa Teixeira (Dec 12 2017 at 20:16):
(before, i was looking at things like optimizing LOINC - CPT - RVU mappings to ensure you get best coverage, so i was just checking)
Grahame Grieve (Dec 12 2017 at 20:16):
so in claim you'd use detail.service + detail.modifier?
nicola (RIO/SS) (Dec 12 2017 at 20:16):
Yes, Grahame
nicola (RIO/SS) (Dec 12 2017 at 20:17):
@Jose Costa Teixeira we have ICD10 & CPT & Insurance Plan mapping
Grahame Grieve (Dec 12 2017 at 20:18):
I don't really know about about CPT to answer with confidence - and I'm working with AMA to resolve that - but this feels the same as ICD-10 dual coding. See http://build.fhir.org/icd.html#dual-coding
nicola (RIO/SS) (Dec 12 2017 at 20:21):
Looks similar - but solution is not very structured (so we have to decode/encode from string literal). Why do not use two codings?
Grahame Grieve (Dec 12 2017 at 21:03):
modifiers are not translations
Paul Knapp (Dec 12 2017 at 23:54):
@nicola (RIO/SS) If you are talking billing, then put the CPT code in Claim.item.service and the modifier in Claim.item.modifier (or detail.service and detail.modifier, or subDetail.service and subDetail.modifier as the case may be)
Grahame Grieve (Dec 13 2017 at 00:30):
@Paul Knapp - what other uses for modifier are there?
Paul Knapp (Dec 13 2017 at 06:35):
@Grahame Grieve I'm not sure I understand your question. Most jurisdictions and disciplines have specific billing code system(s) and modifier code system(s) where the modifier typically conveys a rationale as to why extra costs have been associated with the line item.
Grahame Grieve (Dec 13 2017 at 08:48):
other jurisdictions was the real answer. Where does the modifier come from? Is it in the medical record? or chosen by the person filling out the form?
Paul Knapp (Dec 13 2017 at 08:50):
It is determined usually in concert with the billing code, so 'filling out the form' be that manual or automated.
MaryKay McDaniel (Jan 05 2018 at 15:29):
Grahame,
I've only seen modifiers on claims in the US, I've heard rumors of them in other jurisdictions.
I've paraphrased the definition and use of modifiers here from the 2017 CPT Manual:
Modifiers can be appended to provide additional information about the services rendered. Modifiers are 2 alphanumeric characters. In addition they can be used to bypass NCCI (National Correct Coding Initiative) edits. Only use when appropriate. In general, appropriate relates to separate patient encounters, separate anatomic sites or separate specimens. Most edits involving paired organs or structures (e.g. eyes, ears, extremities, lungs, kidneys) have modifier indicators.
Examples of Modifiers- these are directly quoted from the manual:
"22" - "Increased Procedural Services" with 3 rather large paragraphs in small type explaining what that means.
"25" - "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service", with explanation.
"26" - Professional component
"62" - Two surgeons
"91" - "Repeat clinical diagnostic laboratory test
"A1" - Principle Physician of Record
"P6" - A declared brain-dead patient whose organs are being removed for donor purposes
"LT" - Left side
"RT" - Right side
Mary Kay
Grahame Grieve (Jan 06 2018 at 01:17):
it feels like post-coordination to me
Robert McClure (Jan 15 2018 at 19:52):
@Grahame Grieve It's not post-coordination in a traditional sense (except the right/left thing could be an example of that.) I'm not sure that you could say that post-coordination differs completely from modification anyway - they deeply overlap. So how does saying this seems to be post-coordination help?
Grahame Grieve (Jan 15 2018 at 23:18):
should be an expression in the Coding.code element, not an extra element on the resource
Robert McClure (Jan 16 2018 at 00:24):
Sounds like you are suggesting there be a universal expression syntax for any code system, such as CPT, that does not define one. Are you?
Jay Lyle (Mar 02 2018 at 14:41):
Are implementers hitting this? We could leave CPT modifiers out, though that's suboptimal, especially for the 'not completed' modifiers. Or we could invent a compositional syntax. ICD says use a space. Should we follow that lead?
Paul Knapp (Mar 13 2018 at 06:11):
It is typically a separate codeset from the billing codeset and may include codes for things such as 'performed outside normal office hours' or 'performed on the side of the road'. There may be several modifiers provided with a single billing code. To start now to stop using structured and coded information (code="AB123", modifier="ABC", modifier="DEF" - all with their respective code systems) to create a pseudo information structure in a string (code="AB123 system|ABC system|DEF") would be in my mind a very bad idea.
If however the modifier is part of the code system for the thing being modified, ie. generated by the same SDO, then that would be a post-coordinated codeset, in my mind, where additional systems etc. would not be required and a delimited pattern could be used eg, "proc mod mod".
We have .modifiers in the eClaims related resources in parallel with .service (billing code) to support where the modifier is not a post-coordinated element of the billing code.
Rob Hausam (Mar 13 2018 at 12:41):
In general I would agree. The CPT modifiers being discussed here are part of (or at least closely related to) CPT and are also managed and published by AMA, so I think that the post-coordinated expression notion applies here. That's essentially what you do with them when you fill out the HCFA 1500 for (particularly back in the paper days) - you append them to the primary code. So I think they are relatively analogous to the situation with ICD dual (or multiple) coding.
Last updated: Apr 12 2022 at 19:14 UTC
