Modifiers are two-position alpha or numeric codes (for example, 25, GH, Q6, etc.) which can be appended to a Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) code.
- Professional claims and facility claims can include up to four modifiers per CPT/HCPCS code depending upon the service provided.
When more than one modifier is used, placement of the modifiers is critical for correct reimbursement. Functional modifiers should always be placed in the first modifier field followed by informational modifiers.
Our modifier reimbursement policies include reimbursement details and examples of how to use the modifiers.
Informational modifiers provide additional information about the service rendered. The following modifiers are considered informational by us and therefore not required. These include:
- Modifier - LS FDA-monitored IOL Implant
- Modifier - 90 Reference (Outside) Laboratory
Modifier - QM Ambulance arranged by provider
We recognize all Health Insurance Portability and Accountability Act (HIPAA)-compliant modifiers. A full listing of modifiers can be found in CPT or HCPCS manuals.
- We follow the CMS modifier indicator rules for determining whether a special circumstance could be indicated by a modifier.
CMS NCCI and our CCE code pairs define when two codes may not be reported together except under special circumstances. When these special circumstances are met, the proper modifier should be appended to the appropriate code to describe the circumstance.
Routine colonoscopy or sigmoidoscopy screenings that become diagnostic should be billed with Modifier 33 Preventive Service or Modifier - PT CRC screening test, converted to diagnostic test or other procedure.
Functional modifiers provide additional information that impacts the amount of reimbursement either directly or through the use of Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) or our Correct Code Editor (CCE) edits.
Tips for functional modifier use:
- View our functional modifier list (below).
- Any functional modifier that affects pricing should be placed in the primary position.
- Documentation should be included in the patient's medical record supporting the use of any functional modifier used.
- Coding functional modifiers first may allow the claim to be auto-adjudicated, ensuring your claim is processed quickly.
- Submitting a functional modifier that is not compatible with the base CPT or HCPCS code will cause your claim to be either delayed or denied.
Only submit modifiers when appropriate. Modifier use should relate to separate patient encounters, separate anatomic sites or separate specimens.
We recognize all Health Insurance Portability and Accountability Act (HIPAA)-compliant modifiers. These modifiers can be found listed in the Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) manuals.
We consider the following to be functional modifiers in all instances. Provider agreements may include additional functional modifiers. Review our individual reimbursement policies for details regarding proper use of modifiers.
Alters pricing, see provider agreement
ASC Facility Service
Used Durable Medical Equipment
Unrelated Evaluation and Management (E&M) Service by the Same Physician During a Postoperative Period
Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service
Decision for Surgery
Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
Distinct Procedural Service
Unplanned Return to the Operating/Procedure Room, by the Same Physician During the Postoperative Period
Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Repeat Clinical Diagnostic Laboratory Test
Increased Procedural Services
Changes reimbursement, see policy
Surgical Care Only
Postoperative Management Only
Preoperative Management Only
Procedure Performed on Infants less than 4 kg
73 & 74
Minimum Assistant Surgeon
Assistant Surgeon (when qualified resident surgeon is not available)
Assistant at Surgery, PA, NP or Clinical Nurse Specialist
A patient with severe systemic disease
Changes reimbursement, see policy
A patient with severe systemic disease that is a constant threat to life
A moribund patient who is not expected to survive without the operation
Medical direction of 3 or 4 concurrent anesthesia procedures
CRNA service: with medical direction by a physician
Medical direction of one CRNA by an anesthesiologist
Via asynchronous telecommunication systems (telemedicine)
Allowed, see policy
Required when appropriate
Interactive audio and video telecommunication systems