Surgical Modifiers: Protect Yourself From Instant ‘PC’ Claim Denials

Don’t let ‘wrong surgery’ modifier mistakes stall your reimbursement.

You use modifier TC for the technical component of a test. So logically, you should use modifier PC for the professional component, right? Wrong. But many coders are making that mistake...

Don’t let ‘wrong surgery’ modifier mistakes stall your reimbursement.

You use modifier TC for the technical component of a test. So logically, you should use modifier PC for the professional component, right? Wrong. But many coders are making that mistake and causing their practices unnecessary denial hassles. Here’s what you need to know.

Get ‘Wrong Surgery’ Modifiers Right

When practitioners perform erroneous surgeries, CMS requires the hospital outpatient department, ambulatory surgical center (ASC), physician, or other entity to append one of the following three modifiers to codes for services related to the erroneous procedure effective Jan. 15, 2009:

PA — Surgical or other invasive procedure on wrong body part
PB — Surgical or other invasive procedure on wrong patient
PC — Wrong surgery or other invasive procedure on patient.

“Unfortunately, the introduction of these new modifiers has caused much confusion and they are often being submitted incorrectly,” says Sandra Jongebreur, CGSC,CPC, CPC-H, PCS, FCS, coder for Raafat Abdel-Misih, MD, in Wilmington, Del.

Pause Before Appending PC

In particular, beware of confusing wrong surgery modifier PC with the modifier for the professional component of a procedure: 26 (Professional component). For example, if you want to report that the radiologist performed the professional component of 75966 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation), be sure you append modifier 26 and not modifier PC. If you append modifier PC, the payer will review the claim to see if the service was related to angioplasty performed on a patient in error and therefore not payable.

The source of confusion for these modifiers is easy to see. “People often think of the professional and technical components as PC and TC,” explains Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in New Jersey. The modifier for the “technical component” is TC, so many coders accidentally append PC (instead of 26) forthe professional component.

The problem is so widespread, that CMS issued MLN Matters article 6718 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6718.pdf) warning providers about the issue and announcing that contractors will review all claim lines with modifier PA, PB, or PC.

If the contractor determines the provider used one of the modifiers incorrectly, the contractor will return the claim as unprocessable and ask for submission of a new claim.

Resource: To read CMS’s transmittal on the use of these modifiers, visit www.cms.hhs.gov/transmittals/downloads/R1867CP.pdf.