CMS- Modifiers

Modifiers:

Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code.

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Modifiers can be two digit numbers, two characters, or alpha-numeric. Modifiers provide additional information to the payers to ensure the claim is processed correctly for services rendered.

TC: Technical component

26: Physician component

Side of Body Modifiers

LT Left side of body , RT Right side of body

Eyelid Modifiers:

E1 Upper left, eyelid E3 Upper right, eyelid

E2 Lower left, eyelid E4 Lower right, eyelid

Hand Modifiers:

FA Left hand, thumb F5 Right hand, thumb

F1 Left hand, second digit F6 Right hand, second digit

F2 Left hand, third digit F7 Right hand, third digit

F3 Left hand, fourth digit F8 Right hand, fourth digit

F4 Left hand, fifth digit F9 Right hand, fifth digit

Feet Modifiers

TA Left foot, great toe T5 Right foot, great toe

T1 Left foot, second digit T6 Right foot, second digit

T2 Left foot, third digit T7 Right foot, third digit

T3 Left foot, fourth digit T8 Right foot, fourth digit

T4 Left foot, fifth digit T9 Right foot, fifth digit

Surgical modifiers are required to ensure appropriate payment is made on procedure rendered.

53 Incomplete screening colonoscopy billed on a 96X, 97X and/or 98X revenue code CMS IOM, 

54 Surgical care only. Reported on surgical procedure code distinguishing practitioner providing surgical care only.

55 Postoperative management only. Reported on surgical procedure code distinguishing practitioner providing postoperative management only.

62 Two surgeons. When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding this modifier to single distinct procedure code.

66 Surgical team. This modifier should be used by each participating surgeon to report his/her services. When team surgery is medically necessary, MAC will determine appropriate allowances(s) "by report."

80 Assistant surgeon

81 Minimum Assistant Surgeon

82 Assistant Surgeon (when qualified resident surgeon not available)

AI Principal Physician of Record. CAHs report this modifier to identify primary physician overseeing patient's care from other physicians who may be furnishing specialty care.

AS Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist services for assistant-at-surgery, non-team member.

GC Indicates service has been performed in part by a resident under direction of a teaching physician.

Telehealth modifiers must be submitted with distant site telehealth services. Generally, interactive audio and video communications must be used.

G0 Identifies telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.

GQ Via asynchronous telecommunications system.

GT Via interactive audio and video telecommunication systems to permit 

real-time communication between distant site physician/practitioner and patient. Patient must be present and participating in telehealth visit. 

MACs will accept and pay CPT codes G0108, G0109, G0420, G0421, 96153, 96154, 97804, 99231-99233, 99307-99310 according to appropriate physician or practitioner 

fee schedule amount when submitted with a GQ or GT modifier by a CAH. Providers will need to append either GQ or GT modifier based on type of telehealth communication system used. Change Request (CR)7049 .

Evaluation and Management (E&M) Modifiers

E&M modifiers are used to note special circumstances of a patient's encounter with physician. It is only appropriate to append modifiers 24, 25 and 27 on E&M codes. Documentation in patient's medical record must support use of modifier.

24 Unrelated E&M service by same physician during a postoperative period. This modifier can be used to indicate that an E&M service or eye exam, which falls within global period of a major or minor surgery and is performed by a surgeon, is unrelated to surgery. 

25 Significant, separately identifiable E&M service by the same physician on the same day as the procedure or other service with a 0-day or 10-day global period. 

27 Multiple Outpatient Hospital E&M Encounters on Same Day. 

Incarcerated Beneficiary Modifier

The incarcerated beneficiary modifier may be used to report services for individuals who are in custody including, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities,

QJ Services/items provided to a prisoner or patient in state or local custody;

Laboratory Modifier

Laboratory modifiers are used when laboratory code(s) are separately identifiable and payment is not included in another service.

91 Repeat clinical diagnostic laboratory test. 

QW Clinical Laboratory Improvement Amendments (CLIA) Waived Test.

L1 Provider Attestation that the Hospital Laboratory test(s) is not packaged under Outpatient Prospective Payment System (OPPS).

Outpatient Rehabilitation/Therapy Modifiers

GN Services delivered under an outpatient speech language pathology plan of care.

Preventive Modifiers

GG Diagnostic mammography. Performance and payment of a screening mammography and diagnostic mammography on same patient, on the same day.

33 Claims with dates of service on/or after January 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service (CPT 00810) in conjunction with a screening colonoscopy (HCPCS G0105 or G0121) must include modifier 33 to waive the beneficiary coinsurance and deductible.

Rural Health Clinic (RHC)

FQ Service furnished using audio-only communication technology

GV  Attending physician is not employed or paid under agreement by the patient's Hospice provider.

Surgical/Procedure Modifiers

22 Increased procedural services (surgical/procedures codes only). This should only be used when documentation indicates work performed is substantially greater than typically required by technical difficulty, severity of patient's condition or increased intensity and time.

50 Bilateral procedure. May be used with diagnostic and radiology procedures as well as with surgical procedures.

51 Report for multiple procedures on same day. Do not report on E&M services. This is not required on Medicare claims as the system will apply payment reduction appropriately;

52 Reduced or elimination of a procedure for which anesthesia is not planned.

58 Staged or related procedure or service during postoperative period.

59 Distinct procedural service. Used to identify procedures or services, other than E&M services, that are not normally reported together, but are appropriate under the circumstances.

73 Discontinued outpatient hospital prior to administration of anesthesia. Indicates procedure requiring anesthesia was terminated due to extenuating circumstances or circumstances that threatened well-being of patient after patient had been prepared for procedure.

74 Discontinued outpatient hospital procedure after administration of anesthesia. Indicates a procedure requiring anesthesia was terminated after induction of anesthesia or after procedure was started.

76 Repeat procedure by same physician.

77 Repeat procedure by another physician.

78 Return to operating room for related surgery during postop period. Use on surgical codes only to indicate that another procedure was performed during postoperative period of initial procedure, 

79 Unrelated procedure or service by same physician during a postoperative period. The physician may need to indicate that a procedure or service furnished during a postoperative period was unrelated to original procedure.

XE Separate encounter. A service that is distinct because it occurred during a separate encounter.

XP Separate practitioner. A service that is distinct because it was performed by a different practitioner. 

XS Separate structure. A service that is distinct because it was performed on a separate organ/structure.

XU Unusual non-overlapping service. The use of a service that is distinct because it does not overlap usual components of the main service.

Waiver of Liability Modifiers

GA Waiver of liability statement issues, as required by payer policy. 

GY Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Lines submitted as non-covered and will be Patient Responsibility (PR).

GZ Item or service expected to be denied as not reasonable and necessary. Cannot be used when ABN is given. Lines submitted as non-covered will be denied as provider-liable.