Modifier - as the name implies a modifier will modify a service / procedure or an item under certain circumstances for appropriate reimbursement. Modifiers may add information or change the description according to the physician documentation to give more specificity for the service or procedure rendered. Appending of an appropriate modifier will effectively respond to reimbursement.
Modifier are two digit codes and are categorized into two levels
1. Level I Modifiers: Normally known as CPT Modifiers and consists of two numeric digits and are updated annually by AMA - American Medical Association.
2. Level II Modifiers: Normally known as HCPCS Modifiers and consists of two digits (Alpha / Alphanumeric characters) in the sequence AA through VP. These modifiers are annually updated by CMS - Centres for Medicare and Medicaid Services.
Both the above levels of Modifiers are recognized nationally.
List of Level I Modifiers:
Modifier -21 Prolonged Evaluation and Management Services (Deleted, please use CPT 99354- 99359)
Modifier -22 Unusual Procedural Services
Modifier -23 Unusual Anesthesia
Modifier -24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
Modifier -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Modifier -26 Professional Component
Modifier -27 Multiple Outpatient Hospital E/M Encounters on the Same Date.
Modifier -29 Global procedures, those procedures where one provider is responsible for both the professional and technical component. This modifier has been deleted. If a provider is billing for a global service, no modifier is necessary.
Modifier -32 Mandated Services
Modifier -33 Preventive Service
Modifier -47 Anesthesia by Surgeon
Modifier -50 Bilateral Procedure
Modifier -51 Multiple Procedures
Modifier -52 Reduced Services
Modifier -53 Discontinued Procedure
Modifier -54 Surgical Care Only
Modifier -55 Postoperative Management Only
Modifier -56 Preoperative Management Only
Modifier -57 Decision for Surgery
Modifier -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
Modifier -59 Distinct Procedural Service
Modifier -62 Two Surgeons
Modifier -63 Procedure Performed on Infants less than 4kg
Modifier -66 Surgical Team
Modifier -73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure prior to the Administration of Anesthesia
Modifier -74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure after Administration of Anesthesia
Modifier -76 Repeat Procedure by Same Physician
Modifier -77 Repeat Procedure by Another Physician
Modifier -78 Return to the Operating Room for a Related Procedure During the Postoperative Period
Modifier -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Modifier -80 Assistant Surgeon
Modifier -81 Minimum Assistant Surgeon
Modifier -82 Assistant Surgeon (when qualified resident surgeon not available)
Modifier -90 Reference (Outside) Laboratory
Modifier -91 Repeat Clinical Diagnostic Laboratory Test
Modifier -92 Alternative Laboratory Platform Testing
Modifier -99 Multiple Modifiers
List of Level II Modifiers:
AA Anesthesia services personally performed by anesthesiologist.
AD Medical supervision by a physician: More than 4 concurrent anesthesia procedures.
AE Registered Dietician
AF Specialty Physician
AG Primary Physician
AH Clinical Psychologist
AI Principal Physician of Record
AJ Clinical Social Worker
AK Non Participating Physician
AM Physician, team member service
AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination.
AQ Service performed in a Health Professional Shortage Area
AR Physician providing services in a physician scarcity area
AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member.
AT Acute treatment (chiropractic claims) - This modifier should be used when reporting CPT codes 98940, 98941, 98942 or 98943 for acute treatment.
AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply
AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic
AW Item furnished in conjunction with a surgical dressing
AX Item furnished in conjunction with dialysis services
AY Item or service furnished to an ESRD patient that is not for the treatment of ERSD
AZ Physician providing a service in a dental Health Professional Shortage Area for the purpose of an Electronic Health Record Incentive Payment
A1 Dressing for one wound
A2 Dressing for two wounds
A3 Dressing for three wounds
A4 Dressing for four wounds
A5 Dressing for five wounds
A6 Dressing for six wounds
A7 Dressing for seven wounds
A8 Dressing for eight wounds
A9 Dressing for nine or more wounds
BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services
BL Special Acquisition of blood and blood products
CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission.
CB Services ordered by a dialysis facility physician as part of the ESRD beneficiary's dialysis benefit.
CC Procedure code change- CARRIER USE ONLY - Used by carrier to indicate that the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed.
Automated Multi-Channel Chemistry (AMCC) Tests Modifiers - Effective date: Claims processed on or after April 5, 2010
CD – AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable.
CE – AMCC tests has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity.
CF – AMCC tests has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable.
Modifiers Used to Report the Severity of Functional Limitations (Effective for the year 2013)
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent impaired, limited or restricted
CJ At least 20 percent but less than 40 percent impaired, limited or restricted
CK At least 40 percent but less than 60 percent impaired, limited or restricted
CL At least 60 percent but less than 80 percent impaired, limited or restricted
CM At least 80 percent but less than 100 percent impaired, limited or restricted
CN 100 percent impaired, limited or restricted
CR Catastrophe/Disaster Related
CS Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean-up activities.
DA Oral health assessment by a licensed Health Professional other than a dentist
EA Erythropetic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy.
EB Erythropetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy.
EC Erythropetic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy.
ED Hematocrit level has exceeded 39% (or Hemoglobin level has exceeded 13.0 G/DL) for 3 or more consecutive billing cycles immediately prior to and including the current cycle
EE Hematocrit level has not exceeded 39% (or Hemoglobin level has not exceeded 13.0 G/DL) for 3 or more consecutive billing cycles immediately prior to and including the current cycle.
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
EJ Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab.
EM Emergency reserve supply (for ESRD benefit only)
ET Emergency treatment - Use to designate a dental procedure performed in an emergency situation.
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FB Item provided without cost to provider, supplier or practitioner, or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples)
FC Partial credit received for replaced device
G2 - Most recent URR of 60% to 64.9%
G3 - Most recent URR of 65% to 69.9%
G4 - Most recent URR of 70% to 74.9%
G5 - Most recent URR of 75% or greater
G6 - ESRD patient for whom less than seven dialysis sessions have been provided in a month.
G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening
GA Waiver of liability statement on file - Use to indicate that the physician's office has a signed advance notice retained in the patient's medical record.The notice is for services that may be denied by Medicare.
GC This service has been performed in part by a resident under the direction of a teaching physician.
GD Units of service exceeds medically unlikely edit value and represents reasonable and necessary services.
GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception.
GF Physician services provided by a nonphysician in a critical access hospital; nonphysician: NP, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse (CRN), CNS or PA
GG Diagnostic Mammography - Use to indicated performance and payment of a screening mammography and diagnostic mammography on same patient, on the same day.
GH Diagnostic mammogram converted from screening mammogram on same day
GJ Opted Out physician or practitioner - Use to indicate services performed in an emergency or urgent service.
GM Multiple patients on one ambulance trip
GN Services delivered under an outpatient speech language pathology plan of care.
GO Services delivered under an outpatient occupational therapy plan of care.
GP Services delivered under an outpatient physical therapy plan of care.
GQ Telehealth services via asynchronous telecommunications system
GR This service was performed in whole or in part by a resident in a department of Veterans Affairs Medical Center or clinic supervised in accordance with VA policy.
GS Dosage of EPO or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.
GT Telehealth services via interactive audio and video telecommunication systems
GU Waiver of liability statement issued as required by a payer policy, routine notice
GV Attending physician not employed or paid under agreement by the patient's hospice provider.
GW Service not related to the hospice patient's terminal condition.
GY Use to indicate when an item or service statutorily excluded or does not meet the definition of any Medicare benefit.
GZ Use to indicate when an item or service expected to be denied as not reasonable and necessary.Used when no Advanced Beneficiary Notice (ABN) signed by the beneficiary.
HM Less than Bachelor’s degree level
HN Bachelor’s degree level
HO Master’s degree level
HP Doctoral level
HQ Group setting (for behavioral health use)
HT Multidisciplinary team (for behavioral health use)
Services Funded by by a county, state or federal agency
HU Funded by child welfare agency
HV Funded state addictions agency
HW Funded by state mental health agency
HX Funded by county/local agency
HY Funded by juvenile justice agency
HZ Funded by criminal justice agency
J1 Competitive Acquisition Program, no-pay submission for a prescription number
J2 Competitive Acquisition Program, restocking of emergency drugs after emergency administration
J3 Competitive Acquisition Program, (CAP) drug not available through CAP as written, reimburse under ASP Methodology
JA Administered intravenously
JB Administered subcutaneoulsly
JC Skin substitute used as a graft
JD Skin substitute NOT used as a graft
JW Drug or biological amount discarded/not administered to any patient
KB Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim
KC Replacement of special power wheelchair interface
KD Drug or Biological infused through implanted DME
KE Bid under round one of the DMEPOS competitive bidding program for use with non-competitive bid base equipment
KF Item designated by FDA as Class III device
KL DMEPOS Item Delivered via Mail
KM Replacement of facial prosthesis - including new impression/moulage
KN Replacement of facial prosthesis - Using previous master model
KR Rental item, durable medical equipment – billing for partial month
KX Specific required documentation on file (used for DMERC providers)
KZ New Coverage not implemented by managed care
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LM Left main coronary artery (Effective for the year 2013)
LR Laboratory Round Trip.
LT Left Side - Used to identify procedures performed on the left side of the body.
M2 Medicare Secondary Payer
NB Nebulizer system, any type, FDA-Cleared fo ruse with specific drug
NU New equipment (DME)
P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes
PA Surgery Wrong Body Part
PB Surgery Wrong Patient
PC Wrong Surgery on Patient
Please refer http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6718.pdf for proper usage of PA, PB and PC Modifiers
PD - Diagnostic or related non-diagnostic item or service provided in a wholly owned or wholly operated entity to a patient who is admitted as an inpatient within 3 days, or 1 day. (New modifier for the year 2012, Check for Usage and reimbursement)
PI PET Tumor init tx strategy
PS PET Tumor subsq tx strategy
PT Colorectal cancer screening test; converted to diagnostic test or other procedure
PO Services, procedures and/or surgeries provided at off-campus provider-based outpatient departments
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study.
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study.
Q3 Liver Kidney Donor Surgery and Related Services.
Q4 Service for ordering/referring physician qualifies as a service exemption -
Q5 Service furnished by a substitute physician under a reciprocal billing arrangement
Q6 Service furnished by a locum tenens physician
Q7 One CLASS A finding
Q8 Two CLASS B findings
Q9 One CLASS B and two CLASS C findings
QA FDA Investigational device exemption (IDE) - The IDE project number must be included on the claim when modifier QA is billed.
QB Physician service in a rural HPSA.
QC Single channel monitoring.
QD Recording and storage in solid state memory by a digital recorder.
QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 CFR 411.4 (B)
QK Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals.
QL Patient pronounced dead after ambulance called
QM Ambulance service provided under arrangement by a provider of services
QN Ambulance service furnished directly by a provider of services
QN Ambulance service furnished directly by a provider of services
QP Panel test - Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes.
QS Monitored anesthesia care
QT Recording and storage on tape by an analog tape recorder.
QU Physician service in an urban HPSA.
QV Item or service provided as routine care in a medical qualifying clinical trial
QW CLIA Waived Test - Effective October 1, 1996, all new waived tests are being assigned a CPT code (in lieu of a temporary five-digit G- or Q-code).
QX CRNA service with medical direction by physician.
QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ CRNA service without medical direction by a physician.
RA Replacement of a DME item, Orthotic or Prosthetic Item
RB Replacement of a Part of DME, Orthotic or Prosthetic Item furnished as Part of a Repair
RC Right coronary artery
RD Drug provided to beneficiary, but not, administrated incident-to
RE Furnished in full compliance with FDA-Mandated Risk Evaluation and Mitigation Strategy (REMS)
RI Ramus intermedius (Effective for the year 2013)
RP Replacement and repair
RT Right Side - Used to identify procedures performed on the right side of the body.
RR Rental (use the RR modifier when DME is a rental)
SB NP (for use by midwives only)
SC Medically necessary service or supply (w.e.f Jan 1, 2012)
SF Second opinion ordered by a Professional Review Organization (PRO) per section 9401, P.L. 99-272 (100 % reimbursement – no Medicare deductible or coinsurance)
SG Ambulatory Surgical Center (ASC) modifier
SH Second concurrently administered infusion therapy
SK Member of high risk population (Use only with codes for immunization)
SS Home infusion services provided in the infusion suite of the IV therapy provider
SW Services provided by a certified diabetes educator
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TC Technical component only - Use to indicate the technical part of a diagnostic procedure performed.
TE Licensed Practical Nurse (LPN) (for behavioral health use)
TJ Child/Adolescent Program GP: To be used for enhancement payment for foster care children screening exams.
TK Extra member or passenger, nonambulance transportation
TR School-based individualized education program services provided outside the public school district responsible for the student
TS Follow-up service
UE Used durable medical equipment
UN Portable X-ray Modifiers; two patients
UP Portable X-ray Modifiers; three patients
UQ Portable X-ray Modifiers; four patients
UR Portable X-ray Modifiers; five patients
US Portable X-ray Modifiers; six patients
V1 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to a "minimal" level.
V2 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "self limited or minor" level.
V3 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "low to moderate" level.
V4 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "moderate to high severity" level and of at least 25 minutes duration.
V5 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "moderate to high severity" level and of at least 45 minutes duration.
V6 Arteriovenous Graft (or other vascular access not including a vascular catheter) - Part A only modifier
V7 Afteriovenous Fistula (or other vascular access not including a vascular catheter) - Part A only modifier
V8 Dialysis related infection present during the billing month - Part A only modifier
V9 No dialysis related infection present during the billing month - Part A only modifier
VR Review report - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 to indicate that the service was the treating doctor's review of report(s) only.
XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter,
XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.
Modifier ZA (Anesthesia modifier especially used for Medi-cal insurance of California) denotes prone position or surgical field avoidance. To be used only for procedures that have a base value of three (3) units. These techniques are included in the anesthesia base value of surgical procedures with a base value of more than three.
Modifier ZE (Anesthesia modifier especially used for Medi-cal insurance of California) To be billed with the appropriate five-digit CPT-4 anesthesia code to identify a normal, uncomplicated anesthesia provided by a Certified Registered Nurse Anesthetist (CRNA).
Note: Please check the respective insurance guidelines for appropriate usage of Modifiers to avoid denials.