This page addresses follow-up questions and additional information pertinent to our webinar
Re: It’s A Hospital Thing: CPT/HCPCS Modifiers for Facilities.

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: Is there ever a time when a procedure can be reported in excess of its MUE?
A: Yes, depending on the Medicare Adjudication Indicator (MAI), a procedure may be reported with more units than the MUE allows. MAIs of 1 and 3 may be appealed and paid by the MAC with supporting documentation. Codes with an MAI of 2 are absolute edits and cannot be appealed. MLN Matters MM8853 has more information about MUEs and MAIs (https://www.cms.gov/files/document/revised-modification-medically-unlikely-edit-mue-program-mm8853.pdf).

Q: How do you know if the bilateral modifier applies to a code?
A: The Medicare Physician Fee Schedule (MPFS) lookup tool provides payment policy indicators, including the bilateral surgery indicator.
• 0 = Bilateral surgery rules do not apply, do not use modifier 50
• 1 = Bilateral surgery rules apply; use modifier 50 if bilateral (units = 1)
• 2 = Bilateral surgery rules do not apply. Already priced as bilateral; do not use modifier 50 (units = 1)
• 3 = Bilateral surgery rules do not apply; do not use modifier 50 (units = 1 or 2)
• 9 = Bilateral surgery concept does not apply

The MPFS lookup tool can be accessed at: https://www.cms.gov/medicare/physician-fee-schedule/search

Q: Does the bilateral modifier apply when skin lesions are removed from both extremities?
A: No. The bilateral modifier does not apply to removal of skin lesions because the skin is not a paired organ.

Q: Can codes in category Z53 for canceled procedures be used along with CPT codes with modifiers 52, 73, or 74?
A: Yes, these codes can be used with the modifiers for canceled procedures to explain why a procedure code could not be performed as planned (e.g., contraindication, patient decision).

Q: When an NCCI code pair has a modifier allowance of 0 (not modifiable), which CPT code should be reported?
A: When codes in an NCCI pair have a modifier allowance of 0, meaning that both codes cannot be reported together, even with a modifier, report the code with the highest relative weight. Since both procedures were performed, the facility is entitled to payment for the highest weighted code. This is in line with AHIMA’s Standards of Ethical Coding, section 5.1, which states coding professionals should, “Select and sequence the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements.”