Modifiers Used in CMS-1500 Claim Reporting

Table of Contents

• General Modifier Information
• CPT Modifiers (Used in Medicare Part B)
• HCPCS Modifiers
• ABN Modifiers GA, GX, GY and GZ
• Ambulance Origin and Destination Modifiers

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General Modifier Information

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:

• 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 or
• unusual events occurred.

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CPT Modifiers (Used in Medicare Part B)

Modifier	Definition/Usage
22	Increased procedural services. When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.
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. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service.
24	Unrelated E/M service by the same physician during a postoperative period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate E/M service.
25	Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service: It may be necessary 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
26	Professional component. Certain procedures are a combination of a physician component and technical component. When the physician component is reported separately, the service may be identified by adding 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.
32	Mandated services: Services related to mandated consultation and/or related services (e.g., third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
33	Preventive services. Primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory) the service may be identified by adding modifier 33 to the procedure code.
50	Bilateral procedure. Unless otherwise identified in the listing, bilateral services that are performed at the same operative session, should be identified by adding modifier 50 to the appropriate five-digit code.
51	Multiple procedures. When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (e.g., vaccines), 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) may be identified by appending modifier 51 to the additional procedure or service codes(s). Note: This modifier should not be appended to designated add-on codes (see Appendix D in the CPT book).
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 modifier 52, signifying that the service is reduced. This provides a means or reporting reduced services without disturbing the identification of the basic service. Note: for hospital outpatient 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 (see modifiers approved for ASC outpatient visit use).
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. This circumstance may be reported by adding the modifier ‘53’ to the code reported by the physician for the discontinued procedure. 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/ASC reporting of a previously scheduled procedure/service that is partially reduced or canceled 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 (modifiers approved for ASC and hospital outpatient use).
54	Surgical care only. When one physician or qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, the surgical services should be identified by adding modifier 54 to the usual procedure code.
55	Postoperative management only. When one physician or qualified health care professional performed the postoperative management and another has performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure code.
56	Preoperative management only. When one physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure code.
57	Initial decision for surgery (90-day global period). An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service. 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 procedures or service by the same physician during the postoperative period. It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.
59	Distinct procedural service. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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 no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service performed on the same date, see modifier 25.
62	Two surgeons (co-surgery). When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. The operative report must reflect details for each surgeon’s individual role relative to the procedure(s) billed with a modifier 62. If additional procedures(s) (including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. Note: If 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 code(s) with modifier 80 or modifier 82 added, as appropriate.
66	Surgical team. Under some circumstance, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the surgical team concept. Such circumstances may be identified by each participating physician with the addition of modifier 66 to the basic procedure code used for reporting services. 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 outpatient hospital/ASC procedure prior to the administration of anesthesia.
74	Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia.
76	Repeat procedure or service by same physician. It may be necessary 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 or service.
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. Indicate the reason or the different times for the repeat procedure in Item 19 of the CMS-1500 claim form or the electronic equivalent.
78	Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period. It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures on the same day, see 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. This circumstance may be reported by using modifier 79. (For repeat procedure on the same day see modifier 76.)
80	Assistant surgeon. Surgical assistant services may be identified by adding modifier 80 to the usual procedure code(s).
81	Minimum Assistant Surgeon - Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
82	Assistant surgeon (when qualified resident surgeon not available) The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code(s).
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 code. 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 laboratory tests. In the course of treatment for 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 code 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 same patient.
92	Alternative laboratory platform testing. When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier.
93	Synchronous Telemedicine Service Rendered via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System.
95	Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications.
99	The 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 electronic claim or Item 19 of the CMS-1500 claim form. For Example: 79, RT, LT, QU, GA: Report 99 in the first modifier field on the line of service Report 79, RT, LT, QU, GA in the narrative field of an electronic claim or Item 19 of the CMS-1500 claim form

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HCPCS Modifiers

Alpha Value	Definition/Description
AA	Anesthesia services personally furnished by an anesthesiologist
AB	Audiology service furnished personally by an audiologist without a physician/NPP order for non-acute hearing assessment unrelated to disequilibrium, or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids; service may be performed once every 12 months, per beneficiary.
AD	Medical supervision by physician: more than four concurrent anesthesia procedures
AI	Principal physician of record
AQ	Physician providing a service in an unlisted HPSA (for dates of service on or after 1/1/2006)
AS	Physician assistant, nurse practitioner, or clinical nurse specialist service for assistant at surgery
AT	Acute or chronic active/corrective Treatment (effective 10/1/2004)
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)
CO	Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.
CQ	Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.
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, nonchemo/radio
E1	Upper left, eyelid
E2	Lower left, eyelid
E3	Upper right, eyelid
E4	Lower right, eyelid
FA	Left hand, thumb
FB	Item provided without cost to provider, supplier or practitioner or full credit received for replaced device (examples, but not limited to: covered warranty, replaced due to defect, free samples)
FQ	A telehealth service was furnished using real-time audio-only communication technology
FR	A supervising practitioner was present through a real-time two-way, audio/video communication technology
FS	(Split or Shared E/M Visit) must be reported on claims for split (or shared) visits, to identify that the service was a split (or shared) visit.
FT	Critical Care services billed by a surgeon during a global surgery period when the surgeon’s critical care is completely unrelated to the original surgery.
FX	X-ray taken using film (reduces the technical component for x-ray imaging services provided using film)
FY	Computed radiography services furnished
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
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 1/1/2002)
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 1/1/2002)
GW	Service not related to the hospice patient’s terminal condition (Effective for dates of service on or after 1/1/2002)
J1	CAP no-pay submission for a prescription number
J2	CAP restocking of emergency drugs after emergency administration
J3	CAP drug not available through CAP as written, reimbursed under average sales price methodology
KD	Infusion drugs furnished through implanted DME (Effective 1/1/2004)
KX	Specific required documentation on file
KZ	New coverage not implemented by managed care
LC	Left circumflex coronary artery
LD	Left anterior descending coronary artery
LM	Left main 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 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)
PT	Colorectal cancer screening test; converted to diagnostic test or other procedure
Q0	Investigational clinical service provided in a clinical research study that is in an approved clinical research study
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
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 1/1/06)
QW	CLIA waived test
QX	CRNA service—with medical direction by a physician
QY	Medical direction of one 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 fee-for-time compensation physician
Q7	One class “A” finding
Q8	Two class “B” findings
Q9	One class “B” and two class “C” findings
RC	Right coronary artery
RI	Ramus intermedius
RT	Right side (use to identify procedures performed on the right side of the body)
SG	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. Note: As of 1/1/2008 the SG modifier is no longer applicable.
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	Prediabetic 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 1/1/2004)
UP	Transportation of portable x-rays, three patients served. (Effective 1/1/2004)
UQ	Transportation of portable x-rays, four patients served. (Effective 1/1/2004)
UR	Transportation of portable x-rays, five patients served. (Effective 1/1/2004)
US	Transportation of portable x-rays, six patients or more served. (Effective 1/1/2004)
XE	Separate Encounter: A service that is distinct because it occurred during a separate encounter (effective 1/1/2015) This modifier should only be used to describe separate encounters on the same date of service
XS	Separate Structure: A service that is distinct because it was performed on a separate organ/structure (effective 1/1/2015)
XP	Separate Practitioner: A service that is distinct because it was performed by a different practitioner (effective 1/1/2015)
XU	Unusual Nonoverlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service (effective 1/1/2015)

Related Content

• CMS MLN Fact Sheet: Proper Use of Modifiers 59 & –X{EPSU};

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ABN Modifiers GA, GX, GY and GZ

These modifiers can be used by physicians, practitioners or suppliers to indicate services that are expected to be denied because of lack of medical necessity or statutory exclusion, and those that do not meet the definition of any Medicare benefit. Below are the definitions of each modifier and their appropriate applications.

Reminder: Routine or blanket ABNs are usually not permitted. An ABN should only be given to a Medicare beneficiary when the provider has reason to expect that Medicare will deny payment for some or all of the services. That reason should be listed on the ABN.

Modifier	Description
GA	Waiver of liability statement issued, as required by payer policy.
GX	Notice of liability issued, voluntary under payer policy.
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 (forgot to issue ABN to patient) Note: All claim line items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review.

For more information on ABNs, you may refer to the CMS website Advance Beneficiary Notice of Noncoverage.

GA Modifier: Waiver of liability statement issued as required by payer policy

Used to report when a mandatory ABN was issued to a beneficiary for a covered service that is not likely to be covered by Medicare due to medical necessity. This modifier is frequently used by chiropractors to indicate that spinal manipulation is being provided as maintenance care. Medicare does not reimburse for spinal manipulation that is performed as maintenance care or does not meet for medical necessity.

Facts

• May not be submitted with services that are statutorily excluded. Refer to HCPCS modifier GY for these services.
• May not be submitted, on the same detail line, with chiropractic modifier AT. Effective for dates of service on and after 11/1/2015, services submitted with both modifiers, on the same detail line, will be rejected. Rejected claims must be resubmitted as new claims.
• Indicates the expected denial that an item or service is not reasonable and necessary
• The most common example of these situations would be services adjudicated under an LCD.
• The presence or absence of this modifier does not influence Medicare's determination for payment.
• It is appropriate to report this modifier when the beneficiary refuses to sign the ABN.
• If Medicare determines that the service is not payable, the claim denial is under a “medical necessity denial.”
• Medicare will use claim adjustment reason code 50 (these are noncovered services because this is not deemed a “medical necessity” by the payer) when denying lines due to the presence of the GA modifier.
• Should not be used on a routine basis for all services performed by a provider/supplier.
• Medicare will use claim adjustment reason code 50 (these are noncovered services because this is not deemed a “medical necessity” by the payer) when denying lines due to the presence of the GA modifier.

GX Modifier: Notice of liability issued, voluntary under payer policy

Used to report when a voluntary ABN was issued for a service. The GX modifier would be appended in addition to the GY modifier. The modifier GX was created to report on a claim when a provider has issued an ABN voluntarily for noncovered services.

Facts

• You may use the GX modifier to provide beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute, and in these cases, you may report it on the same line as certain other liability-related modifiers. Please note that the GX modifier must be submitted with noncovered charges only, and your A/B MAC will deny the claim as a beneficiary liability.
• Medicare systems will recognize and allow the GX modifier on claims, but will return your claim if the GX modifier is used on any line reporting covered charges.
• Submit this modifier if you have voluntarily obtained a valid ABN. This includes ABNs obtained for services that are “statutorily denied,” such as physical therapy services provided by chiropractors. You may, but are not required to, ask patients to sign ABNs for services that are “statutorily denied.”
• Part B services will automatically be denied when submitted with HCPCS modifier GX.
• Part A services will automatically be denied when submitted with HCPCS modifier GX.
• You may report this modifier in addition to HCPCS modifiers GY and TS.
• Can be combined with modifiers GY and TS (to indicate beneficiary liability) but not EY, GA, GL, GZ, KB, QL or TQ.
• Lines will automatically deny (using claim adjustment reason code 50) submitted with the GX modifier and noncovered charges, and will assign beneficiary liability to claims automatically denied when the GX modifier is present.

GY Modifier: Notice of liability not issued, not required under payer policy

Should be used on all services that are statutorily excluded or do not meet the definition of any Medicare benefit. Providers do not have to submit claims for noncovered services (e.g., massage, therapy, x-ray, etc.) unless the beneficiary requests claims are submitted, or if a denial is needed for secondary insurance claims processing. Providers may voluntarily use an ABN form to advise beneficiaries of services that Medicare does not cover under any circumstances.

Facts

• Services provided under statutory exclusion from the Medicare Program; the claim would deny whether or not the modifier is present on the claim.
• It is not necessary to provide the patient with an ABN for these situations.
• Modifier GY will cause the claim to deny with the patient liable for the charges.
• Should not use on bundled procedures.
• Should not use on add-on codes.
• Providers that submit claims with the intent of denial for supplemental insurance are not able to submit a routine diagnosis for denial unless all of the reported diagnosis codes are routine noncovered. A combination of the routine diagnosis and the use of the GY modifier will be required for denial.

GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary

Used when a provider does not expect a service to be covered by Medicare, and does not have a valid ABN on file. Beneficiaries are not liable for payment of services, when they were not notified prior to the services being rendered that the service would not be covered by Medicare due to medical necessity.

Facts

• This modifier is an informational modifier only.
• Medicare will adjudicate the service just like any other claim.
• If Medicare determines that the service is not payable, denial is under a “medical necessity.” The denial message will indicate that the patient is not responsible for payment.
• If either the beneficiary or provider requests a review, the modifier tells us that an ABN was not given, and this could help in completing the review quickly.
• Line items denied due to the presence of the GZ modifier will reflect a CARC of 50 (these services are noncovered services because this is not deemed a “medical necessity” by the payer) and a Group Code of CO to show provider/supplier liability.

Related Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12 ‘Physicians/Nonphysician Practitioners’
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50 
• CMS MLN Educational Tool: Advance Beneficiary Notice of Non-Coverage Interactive Tutorial

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Ambulance Origin and Destination Modifiers

The following alpha values must be used in combinations of two to create a two- position ambulance origin/destination modifier. The modifier must indicate both the origin and destination of the run and must be entered for every ambulance trip.

Example: Modifier RH would be used for an ambulance trip from the residence to the hospital.

• The first position alpha value = origin of service.
• The second position alpha value = destination of service

Alpha Value	Definition/Description
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 nonhospital 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	SNF
P	Physician’s office (includes HMO nonhospital 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 nonhospital facility, clinic, etc.)

Revised 9/28/2023