Modifier 63 | Procedure On Infants Explained

Modifier 63 describes a procedure performed on infants less than 4 kg. This article will explain modifier 63, including its definition, when to use it, documentation requirements, billing guidelines, common mistakes, and related modifiers, and end with additional tips.

1. What is modifier 63?

Modifier 63 is a CPT® modifier used to indicate that a procedure involved significantly increased complexity and work because the patient is a neonate or infant weighing under 4 kg. This modifier is not appropriate for codes designated as modifier 63 exempt.

2. When to use modifier 63?

Modifier 63 should be appended to a code for a provider’s procedure on a neonate or infant weighing up to 4 kg, which is roughly 8.8 pounds.

However, note that CPT® indicates modifier 63 is appropriate only for specific procedures, such as those in the Surgery code range and certain Medicine/Cardiovascular codes.

Check coding and payer guidelines for which codes accept modifier 63.

3. Description

The official description of modifier 63 is “Procedure performed on infants less than 4 kg”.

4. Examples

Examples of procedures that require modifier 63 include but are not limited to:

• Neonatal circumcision
• Repair of congenital diaphragmatic hernia
• Repair of gastroschisis
• Repair of omphalocele
• Repair of tracheoesophageal fistula

5. Documentation

When using modifier 63, the procedure documentation must include the patient’s weight.

Payers who request medical records to support the use of the modifier also may look for documentation of the significantly greater effort required and the reason for the additional work, which may include increased intensity or time, technical difficulty not described by a more comprehensive code, severity of the patient’s condition, or increased physical and mental effort.

6. Billing

Because modifier 63 indicates an increased level of difficulty over and above that usually encountered, as well as risk to the infant, payers may reimburse the surgeon an additional fee when you append modifier 63 correctly. In general, you cannot append modifier 63 to codes involving congenital anomalies or increased complexity associated with prematurity valued in the code.

7. Common mistakes

Common mistakes that medical coders make when using modifier 63 include:

• Using modifier 63 for procedures that are not appropriate
• Not including the patient’s weight in the documentation
• Not providing sufficient documentation to support the use of modifier 63

8. Other modifiers related to modifier 63

Other modifiers related to modifier 63 include:

• Modifier 22 – Increased procedural services
• Modifier 52 – Reduced services
• Modifier 66 – Surgical team

9. Tips

Here are some additional tips for using modifier 63:

• Check coding and payer guidelines for which codes accept modifier 63
• Ensure that the documentation includes the patient’s weight and the reason for the additional work
• Do not use modifier 63 for procedures that are designated as modifier 63 exempt