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LIST OF MODIFIERS


Modifier - as the name implies these are the two digit codes that modifies a service / procedure or an item under certain circumstances. 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 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.

Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM6683.pdf

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 

Reference: http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/FunctionalReportingNPC.pdf


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)


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


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 instate or local custody.

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

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

SJ Third or more 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.


TD Registered Nurse (RN) (for behavioral health use)

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


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.


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. 

 

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