Modifiers 1

Modifiers for Medicare Billing For Medicare purposes, modifiers are two-digit codes appended to procedure codes, to provide additional information about the billed procedure. In some cases, addition of a modifier may directly affect payment. Below is a list of modifiers including the modifier description.

AMBULANCE CLAIM MODIFIERS Modifiers that are used on claims for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of X, represents an origin (source) code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code = origin; the second position alpha code = destination. Origin and destination codes and their descriptions are listed below: D E G H I J N P R S X QL

Diagnostic or therapeutic site other than "P" or "H" when these are used as origin codes Residential, domiciliary, custodial facility, nursing home Hospital based dialysis facility (hospital or hospital related) Hospital Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport Non-hospital based dialysis facility Skilled nursing facility (SNF) (Medicare certified beds) Physician’s office (includes HMO non-hospital facility, clinic, etc.) Residence Scene of accident or acute event (Destination code only) Intermediate stop at physician’s office en route to the hospital (includes HMO non-hospital facility, clinic, etc.) Patient Pronounced dead after ambulance called

The following modifiers are valid for Medicare; however, the services would be denied under Medicare Part B as a Part A expense. QM QN

Ambulance service provided under arrangement by hospital Ambulance service furnished directly by hospital

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Billing indicators, listed below, can be used to further clarify the services provided. These billing indicators may be used as additional modifiers.

1A 2A 3A 4A 5A 6A 7A 8A 9A 1B 2B 3B 4B 5B 6B 7B 8B 9B 1C 2C

Bedridden Accidental injury home/nursing home Accidental injury car Patient in shock Oxygen used and/or heart monitor used Transported by stretcher Fracture to hip, leg, knee, trunk (same day as ambulance trip) Hospital lacks facility (patient admitted to second hospital) Rectal bleeding Myocardial infarction Possible cerebral vascular accident (CVA) Black out, passed out Laceration of head Dead on Arrival (DOA) at hospital Died in route to hospital Unresponsive or coma Quadriplegia Stroke (same day as ambulance trip) Paralysis Mentally retarded

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ANCILLARY PERSONNEL MODIFIERS AH AJ AK AL AM AN AS AU AV AW AY GN GO GP GT GX

Clinical Psychologist (CP) Clinical Social Worker (CSW) Nurse Practitioner, rural, team member Nurse Practitioner, non-rural, team member Physician, team member service Physician Assistant (PA) services, for other than assistant-at-surgery, non-team member PA, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery PA services, other than assistant-at-surgery, team member Nurse Practitioner, rural, non-team member Clinical Nurse Specialist, non-team member Clinical Nurse Specialist, team member Service delivered personally by a speech-language pathologist or under an outpatient speechlanguage pathology plan of care Service delivered personally by an occupational therapist or under an outpatient occuptional therapy plan of care Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care Via interactive audio and video telecommunication systems Service not covered by Medicare

ANESTHESIA (A.S.A.) CODE MODIFIERS AA AD AE QK QS QX QY QZ 23 47

Anesthesia services personally performed by anesthesiologist Medical supervision by a physician: More than 4 concurrent anesthesia procedures Direction of residents in furnishing not more than two concurrent anesthesia services - attending physician relationship met Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals Monitored anesthesia care CRNA service with medical direction by physician Medical direction of one concurrent anesthesia procedure involving qualified individuals CRNA service without medical direction by a physician Unusual anesthesia - Used to report a procedure which usually requires either no anesthesia or local anesthesia; however, because of unusual circumstances must be done under general anesthesia Anesthesia by surgeon - Used to report regional or general anesthesia provided by the surgeon (not for local anesthesia)

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AMBULATORY SURGICAL CENTER MODIFIERS 73 74 SG

Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia Ambulatory Surgical Center (ASC) Facility service

DIAGNOSTIC PROCEDURES/PATHOLOGY MODIFIERS 26 90

GH QP QR QW TC

Professional component only - Use to indicate that the physician component is reported separately from the technical component for the diagnostic procedure performed Reference Lab - Used to indicate a lab test sent to an outside lab. e.g., lab procedure performed by a party other than the treating or reporting laboratory. NOTE: Outside lab name, address and UPIN must be included on the claim. Section 20 must be marked "yes" and your actual cost for each test, net any discounts, must be included in the charges section. Diagnostic mammogram converted from screening mammogram on the same day. 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 Repeat clinical diagnostic laboratory test performed on the same day to obtain subsequent reportable test value(s) (separate specimens taken in separate encounters) CLIA waived test Technical component only - Used to indicate that the technical component is reported separately from the professional component for the diagnostic procedure performed

EVALUATION/MANAGEMENT CODE MODIFIERS 4

21

24

25

57

Prolonged evaluation and management services - Use only with highest level of care code for the category when the face-to-face or floor/unit service provided is prolonged or otherwise greater than that usually required for the highest level code. Unrelated E/M service during a post-op period - Use with E/M codes only to indicate that the E/M performed during a postoperative period for a reason(s) unrelated to the original procedure. Modifier 24 applies to unrelated E/M services for either a MAJOR or MINOR surgical procedure. - Failure to use modifier when appropriate may result in denial of the E/M service Separately identifiable service on same day as procedure - Use with E/M codes only to indicate that the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre- and postoperative care for the procedure performed - Failure to use modifier when appropriate may result in denial of the E/M service Decision for surgery - Use with E/M codes billed by the surgeon to indicate that the E/M service resulted in the decision for surgery (E/M visit was NOT usual pre-operative care). For E/M visits prior to MAJOR surgery (90 day post-op period) only. - Failure to use modifier when appropriate may result in denial of the E/M service

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SURGICAL PROCEDURE MODIFIERS LC LD LS LT RC RT 22 50 51 52 53 54 55 56

58

59

62 66 76

Left circumflex coronary artery Left anterior descending coronary artery FDA monitored Intraocular Lens Implant Left side - Used to identify procedures performed on the left side of the body Right Coronary Artery Right side - Used to identify procedures performed on the right side of the body Unusual procedural services - Used only on surgery codes. An operative note should be submitted with the claim Bilateral procedure - Used to indicate bilateral procedures performed during the same operative session. The code with modifier 50 should be billed only once on the claim. Multiple procedures - not required for billing purposes. The carrier will assign the multiple procedure modifier as appropriate based on the services billed. Reduced Services - Use for reporting services that were partially reduced or eliminated at the physician’s election. Documentation should be furnished explaining the reduction. Terminated procedure without complications- for procedures terminated in respect to the patients condition Surgical care only - Use with surgical codes when only the surgical service was performed (another physician is responsible for the pre- and/or postoperative management). Post-operative care only - Use with surgical codes to indicate that only the post-operative care is performed (another physician performed the surgery) Pre-operative care only - DO NOT USE FOR MEDICARE PURPOSES - Payment for this component is included in the allowable for surgery. If another physician performed the surgery, use an appropriate E/M code to bill the pre-op service. Staged or related procedure or service during the postoperative period - This modifier should be used to permit payment for a surgical procedure during the postoperative period of another surgical procedure when (1) the subsequent procedure was planned prospectively at the time of the original procedure, (2) a less extensive procedure fails and a more extensive procedure is required or (3) a therapeutic surgical procedure follows a diagnostic procedure; e.g., a mastectomy follows a breast biopsy. - Failure to use modifier when appropriate may result in denial of subsequent surgery Distinct Procedural Service - Use under certain circumstances where the physician may need to indicate that a procedure is distinct or independent from others services performed on the same day, same provider and are not normally reported together but are appropriate under the circumstances. Two surgeons - When more than one surgeon performed a procedure, the modifier should be used by each surgeon to report his/her services. Surgical team - The modifier should be used by each participating surgeon to report his services. Repeat procedure by same physician -same day

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77 78

79 80 81 82

Repeat procedure - same day, different physician Return to the operating room for a related procedure during the postoperative period - Use on surgical codes only. - Failure to use modifier when appropriate may result in denial of the subsequent surgery Return to the operating room for an unrelated procedure during the postoperative period - Use on surgical codes only. Assistant surgeon Minimum assistant surgeon Assistant surgeon (when qualified resident surgeon not available)

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SURGICAL PROCEDURE EXPANDED MODIFIERS: HANDS - FEET - EYELIDS The following modifiers should be used in conjunction with procedures of the hands, feet and eyelids. The modifiers will not effect payment; however, failure to use these modifiers when appropriate could result in claim delay or denial. E1 E2 FA F1 F2 F3 F4 TA T1 T2 T3 T4

Upper left, eyelid Lower left, eyelid Left hand, thumb Left hand, second digit Left hand, third digit Left hand, fourth digit Left hand, fifth digit Left foot, great toe Left foot, second digit Left foot, third digit Left foot, fourth digit Left foot, fifth digit

E3 E4 F5 F6 F7 F8 F9 T5 T6 T7 T8 T9

Upper right, eyelid Lower right, eyelid Right hand, thumb Right hand, second digit Right hand, third digit Right hand, fourth digit Right hand, fifth digit Right foot, great toe Right foot, second digit Right foot, third digit Right foot, fourth digit Right foot, fifth digit

OTHER MODIFIERS FOR MEDICARE CLAIMS AT CC

EJ EM ET GA

LR QA QB QC QD QT

Acute treatment - this modifier should be used when reporting service A2000 for acute treatment Procedural code change - carrier use only. Used by carrier to indicate that the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed. The remittance statement will indicate the "submitted" code as well as the "new" code used by the carrier. Subsequent claim for Epoetin Alfa-EPO- injection claim only Emergency reserve supply (for ESRD benefit only) Emergency treatment - Use to designate a dental procedure performed in an emergency situation Waiver of Liability statement on file - Use to indicate that the physician’s office has a signed advance notice retained in the patient’s medical record. The notice is for services that may be denied by Medicare - No effect on payment; however, potential liability determinations are based in part on the use of the modifier Laboratory Round Trip Investigational device or related procedure Physician service in a rural HPSA Single channel monitoring Recording and storage in solid state memory by digital recorder Recording and storage on tape by an analog tape recorder 8

QU Q3 Q4 Q5 Q6 99

ZX

Physician service in an urban HPSA Live Kidney Donor - Use for services associated with postoperative medical complications directly related to the donation Service for ordering/referring physician qualifies as a service exemption Service furnished by a substitute physician under a reciprocal billing arrangement Service furnished by a locum tenens physician Multiple modifiers - Use only when more than two modifiers are needed to describe a service. File hard copy. - No effect on payment; however, the individual modifiers listed will apply, including any potential effect they may have on payment. DMERC modifier to identify insulin-dependent beneficiary

LOCALLY ASSIGNED MODIFIERS U2 U3 U4 U5 U6 V2 V3 V4 V5 V6 V7 WA WC WD WE WH WJ XF XT Y2 Y3 Y4

Additional documentation attached Prorated dialysis Monthly Capitation Payment (MCP) due to hospital admission Prorated dialysis Monthly Capitation Payment (MCP) due to transient or temporary patient Prorated dialysis Monthly Capitation Payment (MCP) due to patient death Laparoscopic laser technique Self dialysis training - complete Self dialysis training - incomplete Self dialysis training - subsequent Patient controlled analgesia Rechargeable batteries Reusable electrodes Non-routine care for the sole purpose of determining the need/type of hearing aid Irreversible condition This procedure does not include photo plethysmographic or pulse digit wave form analysis Anesthesia Standby Special billing indicator: "I accept assignment on clinical lab procedure" Procedure code related to routine foot care Radiation therapy final treatment, when 1 or 2 factions are left after multiples of 5 factions have been billed Radiation therapy services when the total treatment consists of 1 or 2 factions First repeat procedure, same date, same provider Second repeat procedure, same date, same provider Third repeat procedure, same date, same provider

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Y5 Y6 Y7 Y8 Y9 Z2 Z3 Z5 Z6

Fourth repeat procedure, same date, same provider Fifth repeat procedure, same date, same provider Sixth repeat procedure, same date, same provider Seventh repeat procedure, same date, same provider Eighth repeat procedure, same date, same provider Ninth repeat procedure, same date, same provider Tenth repeat procedure, same date, same provider No purchased diagnostic services on this claim Pre-anesthesia services up to and including induction when personally furnished by the physician. Payment is based on 3 units and 1 time unit.

MODIFIERS FOR PET (POSITRON EMISSION TOMOGRAPHY) SCAN CODES Note: In addition to the standard modifiers indicating whether the claim is for the professional component only or the technical component, a two-digit modifier should be used to indicate the results of the PET scan and the previous test. The modifier is not required for the technical component - only billings to the intermediary. The first alpha character is used to indicate the results of the PET scan while the second alpha character indicates the results of the prior test. The test result modifiers and their descriptions are listed below: N E P S

Negative Equivocal Positive, but not suggestive of extensive ischemia Positive and suggestive of extensive ischemia (greater than 20% of the left ventricle)

PODIATRY BILLING INDICATORS Billing indicators, listed below, can be used to further clarify the services provided. These billing indicators should be used as additional modifiers. Q7 Q8 Q9 4P 5P

One Class A finding Two Class A findings One Class B and two Class C findings One Class D finding. This condition requires a referring physician Documented mycosis of toenail

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