Humana Changes Reimbursement on Modifiers 53, 78 and 79

HumanaEffective June 22, 2015, Humana will make the following modifier changes to professional claims for their commercial fully insured (including HMOx and select self-funded members), Medicaid and Medicare Advantage HMO, PPO, and private fee-for-service members. However, not all of these products will necessarily be affected by each of the payment policies or modifier updates.

Modifier 53 – Discontinued Services

Professional services submitted with modifier 53 are allowed at 29% of the base allowable amount, subject to any other applicable adjustment. Humana plans that have exceptions to the modifier 53 rule are listed below along with their requirements.

Modifier 53 should only be used when the procedure is discontinued after anesthesia is administered and should not be used when a laparoscopic or endoscopic procedure is converted to an open procedure.

Why?

Humana is aligning their modifier 53 policy with information published by the AMA and Chapter 12 of the Medicare Claims Processing Manual.

Impacted Products

  • Commercial fully insured
  • Select self-funded
  • Medicaid products

Exceptions:

  • Medicare Advantage patients – For a service priced on the basis of MPFS amount, if the MPFS has a specific modifier 53 amount, reimbursement will be based on the MPFS amount, subject to any other applicable adjustment. As of June 22, 2015, the exception applies only to CPT codes 45378 – colonoscopy and 45330 – sigmoidoscopy.
  • Florida Medicaid Products – Humana Florida plans allow professional services submitted with modifier 53 at 25 percent of base allowable amount.
  • Humana Illinois Medicaid plans do not allow services submitted with modifier 53. Services should be reported only when completed entirely.
  • Humana Virginia dual Medicare-Medicaid products allow professional services submitted with modifier 53 based upon the percentage of services completed. An operative report is required in order to make the decision.

Modifiers 78 & 79 – Same Day Usage

Procedures submitted with modifiers 78 (Unplanned return to the OR) or 79 (Unrelated procedure or service to original procedure) on the same date of service as another service are not reimbursable when the use of the modifier is not supported by information on the claim or in the member’s history

Why?

According to the AMA CPT manual, these modifiers indicate that a procedure or service has been altered but not changed in its definition or code. Information must be present to warrant any additional work for reimbursement of CPT codes billed with these modifiers.

Impacted Products

  • Commercial fully insured
  • Select self-funded
  • Medicaid products
  • All Medicare Advantage products

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