MLN Matters® Number: SE0927
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected
This article is for physicians, other practitioners, and providers billing Medicare contractors (carriers, fiscal intermediaries (FIs), and Medicare Administrative Contractors (MACs)) for services provided to Medicare beneficiaries.
Provider Action Needed
STOP – Impact to You
The Healthcare Common Procedure Coding System (HCPCS) modifier PC (Wrong Surgery on Patient) was recently established in CR 6405, along with two other modifiers, for use in Medicare billing, to be appended, where appropriate, to all claim lines related to a surgical error.
CAUTION – What You Need to Know
Some providers or their billing services may be incorrectly using the HCPCS modifier PC to indicate the Professional Component for certain services not related to surgical error when the CPT modifier 26 should have been used. You need to be aware that the use of the HCPCS modifier PC on Medicare claims will result in the claim being denied.
GO – What You Need to Do
Please be sure that you and your billing personnel/services prepare claims submitted to Medicare with the correct codes in order for the claims to process correctly.
Background
This special edition article clarifies the correct use of certain HCPCS/CPT modifiers. To briefly clarify, please note that:
- HCPCS modifier PC is used to identify Wrong Surgery on Patient. The HCPCS modifier PC is to be appended, where appropriate, to all claim lines related to a surgical error.
- CPT modifier 26 is used to identify the professional component of a service or a procedure.
As appropriate, please review MM 6405: Wrong Surgical or Other Invasive Procedures Performed on a Patient, Surgical or Other Invasive Procedures Performed on the Wrong Body Part, and Surgical or Other Invasive Procedures Performed on the Wrong Patient, which explains the wrong surgery HCPCS modifiers. This article is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6405.pdf on the CMS website.
Additional Information
If you have questions, please contact the Palmetto GBA Provider Contact Center at our toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.