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Policy No: 110

Originally Created: 09/01/2009

Section: Modifiers

Last Reviewed: 02/01/2019

Last Revised: 02/01/2019

Approved: 02/07/2019

Effective: 04/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Modifier 63 - Procedure Perfomred on Infants less than 4kg

Current Procedural Terminology (CPT®) modifier 63 represents procedures performed on neonates and infants up to a present body weight of 4 kilograms.

Policy statement

There is a significant increase in work intensity for procedures performed on infants less than four kilograms related to temperature control, obtaining IV access, and the operation itself, which is technically more difficult with regard to maintenance of homeostasis.  The submission of modifier 63 on an appropriate CPT code indicates that the infant's weight is under four kilograms at the time the service is rendered and this low weight resulted in increased work or complexity of work.

CPT modifier 63 is valid for the CPT code range of 20100 – 69999, therefore modifier 63 is not valid with evaluation and management, anesthesia, radiology, pathology, laboratory, or medicine codes.

Medical records may be requested for review to support the additional payment.  Documentation from the patient's record must indicate the significantly greater effort required and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient's condition, or increased physical and mental effort.

The following codes are considered modifier 63 exempt:

30540, 30545, 31520, 33470, 33502, 33503, 33505, 33506, 33610, 33611, 33619, 33647, 33670, 33690, 33694, 33730, 33732, 33735, 33736, 33750, 33755, 33762, 33778, 33786, 33922, 33946, 33947, 33948, 33949, 36415, 36420, 36450, 36456, 36460, 36510, 36660, 39503, 43313, 43314, 43520, 43831, 44055, 44126, 44127, 44128, 46070, 46705, 46715, 46716, 46730, 46735, 46740, 46742, 46744, 47700, 47701, 49215, 49491, 49492, 49495, 49496, 49600, 49605, 49606, 49610, 49611, 53025, 54000, 54150, 54160, 63700, 63702, 63704, 63706, 65820

Modifier 63 is not eligible with procedures codes that include "neonate" or "infant" in the description since the reimbursement rate for the code already reflects the additional work:

00836, 15002, 15003, 15004, 15005,  15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15152, 15157, 15273, 15274, 15277, 15278, 46070, 46705, 49491, 49492, 49495, 49496, 53025, 54160, 61000, 61001, 67229

When a provider reports an eligible procedure or service with modifier 63 appended, reimbursement will be 120% of the established fee.

Modifiers 63 and 22 cannot be billed on the same code.

References

American Medical Association. "Appendix A: Modifiers" Current Procedural Terminology (CPT®). AMA Press.

American Medical Association. "Appendix F: Summary of CPT Codes Exempt from Modifier 63." Current Procedural Terminology (CPT®). AMA Press.

Cross References

Modifier 22; Increased Procedural Services

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.