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Modifiers
Modifiers
CPT Modifiers (Used in Medicare Part B)
HCPCS Modifiers
Ambulance Origin and Destination Modifiers
A list of the most frequently used CPT (Current Procedural Terminology) modifiers, HCPCS (Healthcare Common Procedure Coding System) modifiers has been compiled for your reference.
Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code.
Modifiers may be used to indicate that:
- A service or procedure has both a professional and technical component
- A service or procedure was performed by more than one physician
- A service or procedure has been increased or reduced
- Only part of a service was performed
- An additional service was performed
- A bilateral procedure was performed more than once
- Unusual events occurred
CPT MODIFIERS (Used in Medicare Part B)
| 22 |
Unusual procedural service - Surgeries for which services performed are significantly greater than usually required, may be billed with the 22 modifier added to the CPT code. Include a concise statement about how the service differs from the usual. |
| 23 |
Unusual Anesthesia. |
| 24 |
Unrelated Evaluation & Management 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 therapeutic service which has (0-10 day global period). A separate diagnosis is not needed. This modifier is used on the E &M service |
| 26 |
Professional Component – Certain procedures are a combination of a physician component may be identified by adding the modifier 26 to the usual procedure number. All diagnostic testing with a technical and professional component done in an outpatient or inpatient setting must reflect the 26 modifier. The fiscal intermediary (Part A Medicare) will reimburse the facility for the technical component. |
| 50 |
Bilateral procedure – Bilateral services are procedures performed on both sides of the body during the same operative session or on the same day. Medicare will approve 150 percent of the fee schedule amount for those services. |
| 51 |
Multiple Procedures – Internal use only by Carrier. |
| 52 |
Reduced Services - Use modifier 52 (reduced service) to indicate a service or procedure is partially reduced or eliminated at the physician's election. If claims are submitted electronically with Modifier 52, we will request medical records from the provider before we can process the claims. If claims are submitted on paper for Modifier 52, we expect that medical records will accompany the claim; without this information, your claim may be denied. Include office records, test results, operative notes, or hospital records to substantiate the reason for reporting a reduced service. |
| 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 thepatient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. If claims are submitted electronically with Modifier 53, we will request medical records from the provider before we can process the claims. If claims are submitted on paper for Modifier 53, we expect that medical records will accompany the claim, without this information, your claim may be denied. Include office records, test results, operative notes, or hospital records to substantiate the reason for reporting a reduced service. If this information is not received, your claim may be denied.
One of the most common examples of modifier 53 (this is an exception to the rule) is when an incomplete colonoscopy is performed. Add modifier 53 to CPT code 45378. No documentation is required.
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| 54 |
Surgical care only - When one physician performs a surgical procedure and another physician provides preoperative and/or postoperative management, the surgical service should be identified by adding modifier 54 to the usual procedure code. |
| 55 |
Postoperative management only. When one physician performs the postoperative management and another physician has performed the surgical procedure. |
| 57 |
Initial Decision for surgery (90-day global period). This modifier is used on E&M service, the day before or the day of surgery to exempt it from the global surgery package. |
| 58 |
Staged or related procedure or service by the same physician during the postoperative period. If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately. Modifier 58 must be reported with the second procedure. |
| 59 |
Distinct procedural service - The physician may need to indicate that a procedure or service was distinct or separate from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site, separate lesion, or separate injury. However, when another already established modifier is appropriate, it should be used rather than modifier 59. |
| 62 |
Two surgeons (co-surgery) - Under certain circumstances, the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Adding modifier 62 to the procedure code used by each surgeon should identify the separate service. |
| 66 |
Surgical team - Under some circumstance, highly complex procedures, requiring the accompanying services of several physicians, often of different specialties, plus other highly skilled specially trained personnel, and various types of complex equipment, are carried out under the surgical team concept. Claims with Modifier 66 cannot be processed without a copy of the Operative Report. If claims are submitted electronically with Modifier 66 we will request the operative report before we can process the claims. If claims are submitted on paper for Modifier 66, we expect the operative report will accompany the claim; without this information, your claim may be denied. |
| 73 |
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of
Anesthesia. |
| 74 |
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of
Anesthesia. |
| 76 |
Repeat procedure by same physician: . Indicate the reason or the different times for the repeat procedure in item 19 of the CMS 1500 Form or the electronic equivalent, |
| 77 |
Repeat procedure by another physician. Indicate the reason or the different times for the repeat procedure in item 19 of the CMS 1500 Form or the electronic equivalent. |
| 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. When this subsequent procedure is related to the first, and requires the use of the operating room, it should be reported by adding modifier 78 to the related procedure. |
| 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. |
| 80 |
Assistant surgeon. Add modifier 80 to the usual procedure in a non-teaching setting to identify surgical assistant services |
| 82 |
Assistant surgeon when qualified resident surgeon not available in a teaching setting |
| 90 |
Reference (Outside) Laboratory - When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier 90 to the usual procedure number. For the Medicare program, this modifier is used by Independent Clinical Laboratories when referring tests to a Reference Laboratory for analysis. |
| 91 |
Repeat clinical diagnostic lab tests performed on same day to obtain subsequent reportable test value(s). This modifier is used to report a separate specimen(s) taken at a separate encounter. |
| 99 |
The Multi-Carrier System (MCS) will now allow you to send up to four modifiers per line of service on your claims for both electronically submitted and paper claims. Please indicate the pricing modifiers in the first two positions and processing or informational modifiers in the third and fourth positions.
Use modifier 99 when more than four modifiers are needed on a line of service. In situations that require five or more modifiers, indicate modifier 99 in the first modifier field on the line of service and the remaining modifiers would be entered in the narrative field of an EMC claim or Item 19 of a 1500 claim form. For Example: 79, RT, LT, QU, GA
99 in the first modifier field on the line of service
79, RT, LT, QU, GA in the narrative field of an EMC claim or Item 19 of a 1500 claim form
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HCPCS MODIFIERS
| AA |
Anesthesia services personally furnished by an anesthesiologist |
| AD |
Medical supervision by physician: more than four concurrent anesthesia services |
| AQ |
Physician providing a service in a Health Professional Shortage Area (HPSA) (for dates of service on or after January 1, 2006) |
| AR |
Physician provider services in a physician scarcity area |
| AS |
Physician assistant, nurse practitioner, or clinical nurse specialist service for assistant at surgery |
| AT |
Acute or chronic active/corrective Treatment (effective October 1, 2004). |
| CB |
Services ordered by a dialysis facility physician as part of the ESRD beneficiary's dialysis benefit, is not part of the composite rate, and is separately reimbursable. |
| CC |
Procedure code change (the carrier uses the CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)\ |
| CR |
Catastrophe/Disaster Related |
| EJ |
Subsequent claim for EPO course of therapy. |
| EA |
ESA, anemia, chemo-induced |
| EB |
ESA, anemia, radio-induced |
| EC |
ESA, anemia, non-chemo/radio |
| E1 |
Upper left, eyelid |
| E2 |
Lower left, eyelid |
| E3 |
Upper right, eyelid |
| E4 |
Lower right, eyelid |
| FA |
Left hand, thumb |
| 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 |
| GA |
Advanced Beneficiary Notification on file |
| 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 screening mammogram and diagnostic mammogram on the same patient, same day. (Effective for dates of service on or after 01/01/2002) |
| GJ |
"OPT OUT" physician or practitioner emergency or urgent service |
| GM |
Multiple patients on one ambulance trip |
| GN |
Service delivered under an outpatient speech-language pathology plan of care |
| GO |
Service delivered under an outpatient occupational therapy plan of care |
| GP |
Service delivered under an outpatient physical therapy plan of care |
| GQ |
Via asynchronous telecommunications system |
| GT |
Via interactive audio and video telecommunication system |
| GV |
Attending physician not employed or paid under arrangement by the patient’s hospice provider. (Effective for dates of service on or after 01/01/2002) |
| GW |
Service not related to the hospice patient’s terminal condition. (Effective for dates of service on or after 01/01/2002) |
| 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 and Advanced Beneficiary Notification has not been signed. |
| J1 |
Competitive acquisition program (CAP) no-pay submission for a prescription number |
| J2 |
Competitive acquisition program (CAP) restocking of emergency drugs after emergency administration |
| J3 |
Competitive acquisition program (CAP) drug not available through CAP as written, reimbursed under average sales price methodology |
| KD |
Infusion drugs furnished through implanted Durable Medical Equipment (DME) - (Effective January 1, 2004) |
| KX |
Claims for therapy services that have exceeded therapy caps (either by automatic exception or by approved request), for which there is specific required documentation on file. |
| KZ |
New coverage not implenmented by Managed Care. |
| LC |
Left circumflex coronary artery |
| LD |
Left anterior descending coronary artery |
| LR |
Laboratory round trip |
| LT |
Left side (use to identify procedures performed on the LEFT side of the body) |
| M2 |
Medicare Secondary Payer (used by participating Competitive Acquisition Program (CAP) physicians when a CAP drug is procured from a source other than the CAP vendor because of a mistake in identifying the patient's primary insurer) |
| QA |
FDA investigational device exemption |
| QB |
Physician providing service in a rural HPSA |
| QC |
Single channel monitoring (recording device for holter monitoring) |
| QD |
Recording and storage in solid state memory by a digital recorder (digital recording/storage for holter monitoring) |
| QJ |
Services/items provided to a prisoner or patient in State or local custody. However the state or local government, as applicable, meets the requirements in 42 CFR 411.4 |
| QK |
Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals |
| QL |
Patient pronounced dead after ambulance called |
| QP |
Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes |
| QR |
Services that are covered under a clinical study/trial |
| QS |
Monitored anesthesia care service |
| QT |
Recording and storage on tape by an analog tape recorder |
| QU |
Physician providing services in an urban HPSA (for dates of service prior to January 1, 2006) |
| QV |
Item or service provided as routine care in a Medicare qualifying clinical trial |
| QW |
CLIA waived test |
| QX |
CRNA service - with medical direction by a physician |
| QY |
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist. |
| QZ |
CRNA service - without medical direction by a physician |
| Q3 |
Live kidney donor surgery and related services |
| 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
Class "A" finding: Non-dramatic amputation of foot or integral skeletal portion thereof. |
| Q8 |
Two class "B" findings
Class "B" findings: Absent posterior tibial pulse; Advance tropic changes (hair growth, nail changes, pigmentary changes, or skin texture - three required); absent dorsalis pedis pulse. |
| Q9 |
One class "B" and two class "C" findings
Class "C" findings: Claudication; Temperature changes, edema, paresthesias; burning. |
| RC |
Right coronary artery |
| RT |
Right side (use to identify procedures performed on the RIGHT side of the body) |
| SG |
Ambulatory Surgical Center (ASC) facility charges. This modifier is only used by the ASC for identifying the facility charge. It should not be reported by the physician when reporting his/her professional service rendered in an ASC. Please note as of January 1, 2008 the SG modifier is no longer applicable.
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| TA |
Left foot, great toe |
| T1 |
Left foot, second digit |
| T2 |
Left foot, third digit |
| T3 |
Left foot, fourth digit |
| T4 |
Left foot, fifth digit |
| T5 |
Right foot, great digit |
| T6 |
Right foot, second digit |
| T7 |
Right foot, third digit |
| T8 |
Right foot, fourth digit |
| T9 |
Right foot, fifth digit |
| TC |
Technical component. Under certain circumstances, a charge may be made for the technical component of a diagnostic test only. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. |
| TS |
Pre-Diabetic screening is paid twice within a rolling 12-month period. Second screening to be billed with TS modifier |
| UN |
Transportation of portable x-rays, two patients served - (Effective January 1, 2004) |
| UP |
Transportation of portable x-rays, three patients served - (Effective January 1, 2004) |
| UQ |
Transportation of portable x-rays, four patients served - (Effective January 1, 2004) |
| UR |
Transportation of portable x-rays, five patients served - (Effective January 1, 2004) |
| US |
Transportation of portable x-rays, six patients or more served - (Effective January 1, 2004) |
AMBULANCE ORIGIN AND DESTINATION MODIFIERS
The following values must be used in combinations of two in order to form a two-position modifier. The modifier must indicate both origin and destination. A modifier must be entered for every trip.
| Example: |
Modifier RH would be used for ambulance trip from the Residence to Hospital |
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The first position alphabetic value = origin of service. |
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The second position alphabetic value = destination of service |
| D |
Diagnostic or therapeutic site other than "P" (Physician’s Office) or "H" (Hospital) |
| E |
Nursing Home, residential, domiciliary, custodial facility (other than a Skilled Nursing Facility - SNF) |
| G |
Hospital-based dialysis facility (hospital or non-hospital related) |
| H |
Hospital |
| I |
Site of transfer (e.g., airport or helicopter pad) between types of ambulance vehicles |
| J |
Non-hospital based dialysis facility |
| N |
Skilled nursing facility (SNF) |
| P |
Physician’s office (includes HMO non-hospital facility, clinic, etc.) |
| R |
Residence |
| S |
Scene of accident or acute event |
| X |
(Destination code only) Intermediate stop at physician’s office on the way to the hospital (include HMO non-hospital facility, clinic, etc.) |
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