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physcial status modifiers

Pauline Posted Thu 06th of March, 2014 17:25:41 PM

We are having reimbursement issues with Blue Shield underpaying on anesthesia due to a flat rate with the 2013 policy. We were not using the physical status modifiers and will start to do this. We checked with BS and they said the order should be "P3, AA (OR)QZ, QS, but as you all know if I call back, I may get a different answer!

I see some post that the physical modifier should be second or last.

Does Medicare and Medical not recognize the modifier in 2014?
Do you recomend that we use the physical status modifier with all carriers?

Any other advice on this issue?

Thank you for you help with this.

SuperCoder Answered Thu 06th of March, 2014 19:07:26 PM

My editor is working on this query.


SuperCoder Answered Fri 07th of March, 2014 03:16:48 AM

Medicare does not recognize Physical Status P modifiers. This is not a new 2014 rule, in fact this in place for quite some time.

Physical status modifiers commonly known as P-modifiers are unique to the reporting of claims for anesthesia services. These modifiers help to distinguish between levels of complexity in providing anesthesia services comparative to patient health circumstances. Because of different levels of complexity in providing anesthesia to patients of varying health states, use of a P-modifier can sometimes add an additional base unit (or units) when reported accurately on a claim submission.

As per BCBS of NC -- "Blue Cross and Blue Shield of North Carolina’s (BCBSNC) existing claim submission policy requires a P-modifier (reporting the patient’s condition) to be placed in the first modifier position, following the five-digit procedure code, of any claim submission or electronic transaction reporting anesthesia services..... BCBSNC has in the past made efforts to correct P-modifier billing errors and manually review and process those claims to recognize P-modifiers reported in secondary positions, as if the modifiers had been reported in the first position of the modifier field. However, in order to streamline efficiencies and help control administrative costs, as of May 1, 2012, we will begin processing anesthesia claims recognizing P-modifiers based only on the order they’ve been submitted, in accordance with existing policy. This means that claims appended with P-modifiers located in positions other than the first position of the modifier field will not be eligible to receive P-modifier-associated additional units added to the anesthesia base values. As of May 1st and afterwards, only claims reported following BCBSNC’s existing billing requirement to place an appropriate anesthesia P-modifier in the first position after the procedure, listed before other modifiers reported on the anesthesia claim, will be processed recognizing additional base value considerations."

As a general rule, payment modifiers come first and then the informational (& non-payment) modifiers are placed in claims, unless a specific rule is laid out by a payer. As payment modifiers, P3 is equivalent to 1 unit, P4 for 2 units and P5 for 3 units in anesthesia payment calculation.

Use of P-status mods. depends on payer rules, so always go by the specific payer's policy in this regard. Some examples: Workers compensation and no-fault insurance carriers in New York state pay for physical status modifiers. Medicare and some other carriers do not. Medicaid carriers in California, Virginia, and some other states don't reimburse for higher physical status codes. And, Meridian, a major carrier in the Midwest and West, refuses reimbursement of additional money for physical status or other qualifying anesthesia codes used with Medicare patients.

Pauline Posted Fri 07th of March, 2014 16:48:44 PM

Thank you so much for your time.

SuperCoder Answered Tue 11th of March, 2014 14:41:30 PM

You are always welcome!

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