MODIFIERS are 2 digit alpha or numeric or
alphanumeric, used with CPT codes to describe or adding extra information about
the service provided by the physician to the patient.
TYPES OF MODIFIERS
Level I – CPT modifiers
Level II – HCPCS Alphanumeric Modifiers
Level I and II modifier definitions are listed in the Healthcare Common
Procedure Coding System II.
Modifiers Position in
claims.
- The Medicare claim form contains two modifier fields (item 24 d).
- When entering only one modifier, enter it in the first modifier
field.
- When entering a pricing modifier, enter it in the first modifier field
only.
E.g., when billing for the professional component (26) or the
technical component (TC) enter the 26 or the TC modifier in the first modifier
field.
- When entering a pricing modifier and a statistical modifier that
affects pricing; enter the pricing modifier in the first modifier field and the
statistical modifier that affects pricing in the second modifier field.
E.g., when billing for the professional component (modifier 26) in a
Health Professional Shortage Area (HPSA) (modifier QB) enter 26 in the first
modifier field and QB in the second modifier field.
- When entering a statistical modifier that affects pricing and a
statistical/informational modifier, enter the statistical modifier in the first
field and the statistical/informational modifier in the second field.
E.g., when billing for the professional component (modifier 26)
and repeated procedure by the same physician (modifier 76) enter 26 in the
first modifier field and the 76 in the second modifier field.
- When entering more than one statistical/informational modifier with no
modifiers that affect pricing, it does not matter which modifier is entered
first.
The exception is for the QT, QW and SF modifiers. These three modifiers are
valid in the first modifier field only.
- When more than four modifiers apply, enter modifier 99 in the first
modifier field. In the narrative field (item 19 on the claim form) list all
modifiers in the correct ranking order being sure to identify which detail line
or procedure code to which the modifiers apply.
Level
I (Or) CPT Modifiers
22- Unusual Procedural Services:
When the service(s) provided is greater than that
usually required for the listed procedure. Note: This modifier is not to be
used to report procedure(s) complicated by adhesion formation, scarring, and/or
alteration of normal landmarks due to late effects of prior surgery,
irradiation, infection, very low weight (Neonates and infants less than 10 kg.)
or trauma.
23-Unusual Anesthesia:
Occasionally, a procedure, which usually requires
either no anesthesia or local anesthesia, because of unusual circumstances,
must be done under general anesthesia.
24-Unrelated E&M Service, Same Physician, During Postoperative
Period:
The physician may need to indicate that an E&M service
was performed during a postoperative period for a reason(s) unrelated to the
original procedure.
25-Significant, Separately Identifiable E&M Service by the Same
Physician on the Same Day of the Procedure or Other Service:
The physician may need to indicate that on the day a procedure or
service identified by a CPT code was performed, the patient’s condition
required a significant, separately identifiable E&M service above and
beyond the other service provided or beyond the usual preoperative and
postoperative care associated with the procedure that was performed. The
E&M Service may be prompted by the symptom or condition for which the
procedure was provided. As such, different diagnoses are not required for
reporting the E&M services on the same date. The circumstance maybe
reported by adding modifier 25 to the appropriate level of E&M service.
26-Professional Component:
Certain
procedures are a combination of a physician component and a technical
component. When the physician component is reported separately, the service may
be identified by adding the modifier 26 to the usual procedure number. Note:
The 26 modifier should not be appended to procedure codes that represent a
professional component (example: 93010).
32-Mandated
Services:
Services related to mandated consultation and/or
related services (e.g., Peer Review Organization (PRO), 3rd party payer,
governmental, legislative or regulatory requirement).
47-Anesthesia by
Surgeon:
Regional or general anesthesia provided by the
surgeon.
50-Bilateral
Procedure:
Unless otherwise identified in the listings, bilateral
procedures that are performed in the same operative session should be
identified by adding the modifier 50 to the appropriate five-digit CPT
code.
51-Multiple
Procedures:
When multiple procedures, other than E&M services, are
performed at the same session by the same provider, the primary procedure or
service may be reported as listed. The additional procedure(s) or service(s)
maybe identified by appending the modifier 51 to the additional procedure or
service code(s).
Note: This modifier should not be appended to designated
"add-on" codes
52-Reduced Services:
Under certain circumstances, a service or procedure is
partially reduced or eliminated at the physician’s discretion. Under these
circumstances the service provided can be identified by its usual procedure
number and the addition of the modifier 52, signifying that the service is
reduced. This provides a means of reporting reduced services without disturbing
the identification of the basic service. Note: For outpatient hospital
reporting of a previously scheduled procedure/service that is partially reduced
or cancelled as a result of extenuating circumstances or those that threaten
the well-being of the patient prior to or after administration of anesthesia,
see modifiers 73 and 74.
53-Discontinued
Procedure:
Under certain circumstances, the physician may elect to
terminate a surgical or diagnostic procedure. Due to extenuating circumstances
or those that threaten the well-being of the patient, it may be necessary to
indicate that a surgical or diagnostic procedure was started but discontinued.
Note: This modifier is not used to report the elective cancellation of a
procedure prior to the patient’s anesthesia induction and/or surgical
preparation in the operating suite. For outpatient hospital/ambulatory surgery
centre (ASC) reporting of a previously scheduled procedure/service that is
partially reduced or cancelled as a result of extenuating circumstances or
those that threaten the well-being of the patient prior to or after
administration of anesthesia, see modifiers 73 and 74.
54-Surgical Care
Only:
When one physician performs a surgical procedure and
another provides preoperative and/or postoperative management.
55-Postoperative
Management Only:
When one physician performs the postoperative management and
another physician has performed the surgical procedure.
56-Preoperative
Management Only:
When one physician performs the preoperative care and evaluation
and another physician performs the surgical procedure.
57-Decision for Surgery:
An E&M service
that resulted in the initial decision to perform the surgery
58-Staged or
Related Procedure or Service by the Same Physician During the Postoperative
Period:
The physician may need to indicate that the performance of a
procedure or service during the postoperative period was: (A) planned
prospectively at the time of the original procedure (staged); or (B) more
extensive than the original procedure; or (C) for therapy following a
diagnostic surgical procedure.
Note: This modifier is not used to report the treatment of a problem that
requires a return to the operating room. See modifier 78
59-Distinct
Procedural Service:
Under certain circumstances, the physician may need to indicate
that a procedure or service was distinct or independent from other services
performed on the same day. Modifier 59 is used to identify procedures/services
that are not normally reported together but are appropriate under the
circumstances. This may represent a different session or patient encounter,
different procedure or surgery, different site or organ system, separate
incision/excision, separate lesion, or separate injury (or area of injury in
extensive injuries) not ordinarily encountered or performed on the same day by
the same physician. However, when another already established modifier is
appropriate, it should be used rather than modifier 59. Only if there is not a
more descriptive modifier available, and the use of modifier 59 best explains
the circumstances, should modifier 59 be used.
62-Two Surgeons:
When two surgeons work together as primary surgeons
performing a distinct part(s) of a single reportable procedure, each surgeon
should report his/her distinct operative work by adding the modifier 62 to the
single definitive procedure code. Each surgeon should report the co-surgery
once using the same procedure code. If an additional procedure(s) (including
add-on procedure(s)) are performed during the same surgical session, separate
code(s) may be reported without the modifier 62 added.
Note: If a co-surgeon acts as an assistant in the performance of additional
procedure(s) during the same surgical session, those services may be reported
using separate procedure(s) with the modifier 80 or 81 added, as appropriate.
73-Discontinued
Outpatient Hospital/ASC Procedure Prior to the Administration of
Anesthesia:
Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic
procedure subsequent to the patient’s surgical preparation (including sedation
when provided, and being taken to the room where the procedure is to be
performed), but prior to the administration of anesthesia. Under these
circumstances, the intended service that is prepared for but cancelled can be
reported by its usual procedure number and the addition of the modifier 73.
Note: The elective cancellation of a
service prior to the administration of anesthesia and/or surgical preparation
of the patient should not be reported.
74-Discontinued
Outpatient Hospital/ASC Procedure after Administration of Anesthesia:
Due to extenuating circumstances or those that threaten the
well-being of the patient, the physician may terminate a surgical or diagnostic
procedure after the administration of anesthesia or after the procedure was
started. Under these circumstances, the procedure started but terminated can be
reported by its usual procedure number and the addition of modifier 74.
Note: The elective cancellation of a service prior to the administration of
anesthesia and/or surgical preparation of the patient should not be reported.
76-Repeat
Procedure by the Same Physician:
The physician may need to indicate that a procedure or
service was repeated subsequent to the original procedure or service. This
circumstance may be reported by adding modifier 76 to the repeated procedure.
77-Repeat
Procedure by Another Physician:
The physician may need to indicate that a basic procedure or
service performed by another physician had to be repeated. This situation may
be reported by adding modifier 77 to the repeated procedure or service.
78-Return to the
Operating Room for a Related Procedure During the Postoperative Period:
The physician may need to indicate that another procedure was
performed during the postoperative period of the initial procedure. (For repeat
on the same day, see modifier 76.)
79-Unrelated
Procedure or Service by the Same Physician During the Postoperative Period:
The physician may need to
indicate that the performance of a procedure or service during the
postoperative period was unrelated to the original procedure. (For repeat
procedures on the same day, see modifier 76.)
80-Assistant
Surgeon:
Surgical assistant services may be identified by adding the
modifier 80 to the usual procedure number(s).
82-Assistant
Surgeon (when a qualified resident surgeon is not available in a teaching
facility):
The unavailability of a qualified resident surgeon is
a prerequisite for use of this modifier.
90-Reference
(Outside) Laboratory:
Physician’s use of this modifier when laboratory
procedures are performed by a party other than the treating or reporting
physician
91-Repeat Clinical
Diagnostic Laboratory Test:
In the course of treatment of the patient, it may be
necessary to repeat the same laboratory test on the same day to obtain
subsequent (multiple) test results. Under these circumstances, the laboratory
test performed can be identified by its usual procedure number and the addition
of modifier 91.
Note: This modifier may not be used when tests are rerun to
confirm initial results; due to testing problems with specimens or equipment;
or for any other reason when a normal, one-time, reportable result is all that
is required. This modifier may not be used when other code(s) describe a series
of test results (e.g., glucose tolerance tests, evocative/suppression testing).
This modifier may only be used for laboratory test(s) performed more than once
on the same day on the same patient
99-Multiple
Modifiers:
Under certain circumstances more than four modifiers
may be necessary to completely delineate a service.
Level
II - HCPCS Alpha-Numeric Modifiers
*AA- Anesthesia services
performed by anesthesiologist.
*AD- Medical supervision by
a physician, more than four concurrent anesthesia procedures.
AH- Clinical Psychologist
Services.
AI - Principal physician
AJ- Clinical Social Worker
(CSW). [Used when a medical group employs a CSW and bills for the CSW’s
service.]
AM- Physician, team member
service
AS- Physician Assistant,
Nurse Practitioner, or Clinical Nurse Specialist services for assistant at
surgery.
AT- Acute treatment. [This
modifier should be used when reporting a spinal manipulation service (codes
98940, 98941, and 98942.)]
CC- Procedure code changed.
[This modifier is used when the submitted procedure code is changed either for
administrative reasons or because an incorrect code was filed.]
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 (example: EPO, sodium hyaluronate)
EM- Emergency reserve
supply (for ESRD benefit only).
EP- Service provided as
part of Medicaid early periodic screening diagnosis and Treatment (EPSDT)
program.
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.
FA- Left Hand, Thumb.
FP- Service Provided as
Part of Medicaid Family Planning Program.
G1- Most recent urea
reduction ratio (URR) reading of less Than 60.
G2- Most recent urea
reduction ratio (URR) reading of 60 to 64.9.
G3- Most recent urea
reduction ratio (URR) of 65 to 69.9.
G4- Most recent urea
reduction ratio (URR) of 70 to 74.9.
G5- Most recent urea
reduction ratio (URR) reading of 75 or greater.
G6- ESRD patient for whom
less than six dialysis sessions have been provided in a month.
G7- Pregnancy resulted from
rape or incest or pregnancy certified by a physician as life-threatening.
G8- Monitored Anesthesia
Care (MAC) for deep complex, complicated, or markedly invasive surgical
procedure.
G9- Monitored Anesthesia
Care (MAC) for a patient who has a history of severe cardiopulmonary
condition.
GA- Waiver of Liability
Statement on file. (Effective for dates of service on or after October 1, 1995,
a physician or supplier should use this modifier to note that the patient has
been advised of the possibility of non-coverage.)
GB- Claim being
re-submitted for payment because it is no longer covered under a global payment
demonstration.
GC- This service has been
performed in part by a resident under the direction of a teaching physician.
GE- This service has been
performed by a resident without the presence of a teaching physician under the
primary care exception.
GG- Performance and payment
of a screening mammogram and diagnostic mammogram on the same patient, same
day.
GH- Diagnostic mammogram
converted from screening mammogram on the same day.
GJ- "Opt-Out"
physician or practitioner emergency or urgent service.
GM- Multiple patients on
one ambulance trip.
GN- Service delivered
personally by a speech-language pathologist or under an outpatient
speech-language pathology plan of care.
GO- Service delivered
personally by an occupational therapist or under an outpatient occupational
therapy plan of care.
GP-Service delivered
personally by a physical therapist or under an outpatient physical therapy plan
of care.
GQ- Via asynchronous
telecommunications system
GT- Via interactive audio
and video telecommunication systems.
GV- Attending physician not
employed or paid under an arrangement by the patient’s hospice provider.
GW- Service not related to
the hospice patient’s terminal condition.
GY- Item or service
statutorily excluded or does not meet the definition of any Medicare benefit.
GZ- Item or service
expected to be denied as not reasonable and necessary.
KD - Any “Drug or biological substance infused
through a DME
KO- Single drug unit dose
formulation.
KP - The first drug of a
multiple drug unit dose formulation.
KQ- Second or subsequent
drug of a multiple drug unit dose formulation.
LC- Left circumflex
coronary artery.
LD- Left anterior
descending coronary artery.
LR- Laboratory round trip.
LS- FDA-monitored
intraocular lens implant.
LT- Left Side. (Used to
identify procedures performed on the left side of the body.)
PO - Outpatient hospital services furnished in an
off-campus provider-based department
Q3- Live kidney donor -
Services associated with postoperative medical complications directly related
to the donation.
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.
QB- Physician providing
service in a rural Health Professional Shortage Area (HPSA).
QC- Single-channel
monitoring.
QD- Recording and storage
in solid-state memory by a digital recorder.
*QK- Medical direction of
two, three, or four concurrent anesthesia procedures involving
qualified individuals.
QL- Patient pronounced dead
after ambulance called.
QM- Ambulance service
provided under an arrangement by a provider of services.
QN- Ambulance service
furnished directly by a provider of services.
QP- Documentation is on
file showing that the laboratory test(s) was ordered individually or ordered as
a CPT-recognized panel other than an automated profile codes 80002-80019,
G0058, G0059, and G0060.
QQ- Claim submitted with a written statement of intent.
QS- Monitored anesthesia
care service.
*QT- Recording and storage
on tape by an analogue tape recorder.
QU- Physician providing
service in an urban Health Professional Shortage Area (HPSA).
QV- Item or service
provided as routine care in a Medicare qualifying clinical trial.
*QW-Clinical Laboratory
Improvement Amendment (CLIA) waived test (modifier used to identify waived
tests).
*QX- CRNA service with
medical direction by a physician.
*QY- Anesthesiologist
medically directs one CRNA.
QZ- CRNA service without
medical direction by a physician.
RC- Right coronary artery.
RT- Right Side (used to
identify procedures performed on the right side of the body).
*SF- The 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) facility service.
SL - VACCINE FOR CHILDREN
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.
TA- Left Foot, Great Toe.
*TC-Technical Component.
Under certain circumstances, a charge may be made for the technical component
alone. Under those circumstances, adding modifier TC to the usual procedure
number identifies the technical component charge. Note: The TC modifier should
not be appended to procedure codes that represent the technical component
(example: 93005).
*UN- Two patients served.
*UP- Three patients served.
*UQ- Four patients served.
*UR- Five patients served.
*US- Six patients or more
served.
XE - Separate Encounter
XS - Separate Structure
XP - Separate Practitioner
XU - Unusual Non-Overlapping Service
(Note: * Denotes modifiers which are valid for the first
modifier field only).