Modifiers

Modifiers

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

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.

Preventive services modifiers

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.

View NCCI bypass modifier exceptions.

Functional modifiers

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.

Functional modifier list

Modifier

Description

Potential impact

NU

New Equipment

Alters pricing, see provider agreement   

RR

Rental (DME)

SG

ASC Facility Service

UE

Used Durable Medical Equipment

24

Unrelated Evaluation and Management (E&M) Service by the Same Physician During a Postoperative Period

25

Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service

57

Decision for Surgery

58

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

59

Distinct Procedural Service

78

Unplanned Return to the Operating/Procedure Room, by the Same Physician During the Postoperative Period

79

Unrelated Procedure or Service by the Same Physician During the Postoperative Period

91

Repeat Clinical Diagnostic Laboratory Test

22

Increased Procedural Services

Changes reimbursement, see policy

26

Professional Component

50

Bilateral Procedure

51

Multiple Procedures

52

Reduced Services

54

Surgical Care Only

55

Postoperative Management Only

56

Preoperative Management Only

62

Two Surgeons

63

Procedure Performed on Infants less than 4 kg

66

Surgical Team

73 & 74

Discontinued Services

80

Assistant Surgeon

81

Minimum Assistant Surgeon

82

Assistant Surgeon (when qualified resident surgeon is not available)

AS

Assistant at Surgery, PA, NP or Clinical Nurse Specialist

TC

Technical Component

P3

A patient with severe systemic disease

Changes reimbursement, see policy

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

QK

Medical direction of 3 or 4 concurrent anesthesia procedures

QX

CRNA service: with medical direction by a physician

QY

Medical direction of one CRNA by an anesthesiologist

GQ

Via asynchronous telecommunication systems (telemedicine)

Allowed, see policy

53

Required when appropriate

GT

Interactive audio and video telecommunication systems

JW