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Modifier -80

Nancy Posted Wed 18th of May, 2011 19:01:55 PM

Can anyone know if there are any guidelines specifying medical necessity requirements on the usage of modifier -80?

For example: Two trauma surgeons going in the OR to assistant one another just to finish the procedure more quick?

I don't agree with the above example, but I can't find anything telling us differently.

Any help would be appreciated! Thanks so much!

SuperCoder Answered Wed 18th of May, 2011 21:04:53 PM

Guidelines/Instructions on Modifier -80:

•This modifier may only be submitted with surgery codes
•Physician assistants, nurse practitioners and clinical nurse specialists must not submit this modifier. See HCPCS Modifier AS.
•Supporting documentation describing the medical necessity for an assistant must be submitted with the claim for services that are Asst Surg Indicator 0 on the Medicare Physician Fee Schedule Database (MPFSDB)
•In addition, documentation to support one of the following situations is required in the medical record when the surgery is performed in a teaching hospital:
◦A statement that no qualified resident was available to perform the service
◦A statement indicating that exceptional medical circumstances exist
◦A statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients

...
To determine whether the services of an assistant may be submitted to Medicare with CPT Modifier 80, refer to the MPFS from SuperCoder:-
...

•Go to the details section of any CPT code.
◦Click on the "Fee Schedule" tab on the right hand side.
◦Scroll down to the bottom of the page.
◦Refer to the column heading ‘Asst Surg’
•Indicator 0 corresponds to payment restriction for assistants at surgery applies to this procedure. Supporting documentation describing the medical necessity for an assistant must be submitted with the claim.
•Indicator 1 corresponds to statutory payment restriction for assistants at surgery applies to this procedure. Assistants at surgery will not be paid.
•Indicator 2 corresponds to payment restriction for assistants at surgery does not apply to this procedure. Assistants at surgery may be paid.
•Indicator 9 corresponds to concept does not apply (the most likely explanation is that the procedure is not a surgery)

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