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					GENERAL INFORMATION:
Modifiers are used to denote that a certain procedure/service has been altered by a particular circumstance, but not changed in
its definition, therefore the same code is used and a modifier is added to denote what has been altered. The Transaction Master
(Setup & Support, Option #2) contains modifier usage information related to billing transaction (CPT) codes with modifiers. F1
Help at 'Mod Flag' field contains information related to identifiers from the Medicare Physician Fee Schedule Database
(MPFSDB).

Modifier Tips:
When modifier decreases the reimbursement, let the payor reduce the fee to avoid a double reduction.
When modifier increases the reimbursement, increase fee accordingly before the claim is sent.
Always place payment modifiers before informational modifiers. (Excerpt: 13th Annual Compliance Seminar)
Documentation supporting the use of any modifier must be found in the record. (Excerpt: 13th Annual Compliance Seminar)
Watch for 'red flag' modifiers, i.e., 25, 59, and modifiers restricted to a specific type of service, i.e., those specific to E&M,
surgical, etc. (Excerpt: 13th Annual Compliance Seminar)

                          ***INFORMATION IS SUBJECT TO CHANGE PER CARRIER DIRECTIVE***

CPTs Utilized Key:
   E       Evaluation & Management
   A       Anesthesia
   S       Surgery (Medicare Global Surgery Packages)
   R       Radiology
   L       Laboratory & Pathology
   M       Medicine (Immunizations, Injections, Specialty-Specific Codes, Special Services)
   D       DMEPOS
   O       Approved for Ambulatory Surgery Center (ASC) & Hospital Outpatient Use

$ Impact Key:
    UP    Reimbursement goes up
    PD    Claim gets paid - without modifier claim denied
    DN    Reimbursement goes down (as compared to total component)
    SM    Reimbursement stays the same (informational only)

All Others:
     *     Report may be needed for claim processing
     **    Report/supporting documents required for claim processing
           Not recommended for use with this CPT code range - possible mistake in fee schedule - only listed on 3 CPT codes
      !
           (!! 10 CPT codes)
     Y     Modifier can be used for this carrier
    Yx     Modifier only acceptable on crossover claims
     N     Modifier can NOT be used for this carrier

Special Handling/Carrier Specific:
MSI maintains a table for carrier specific modifier usage by claim type. See Help Text for complete list.
To view the table on screen, key on a command line (press F10): RUNQRY *N MPMS/QMOD
To generate a report that can be printed/released to print or viewed on user's spool file, key on a command line (press F10):
  RUNQRY QRYFILE((MPMS/QMOD)) OUTTYPE(*PRINTER)
For any questions, contact Software Support at support@medtronsoftware.com.
The modifiers listed are automatically pulled as defaults from the Place of Service, Office Location or Charge Transaction
Masters to the charge line at charge entry on charges based on primary insurance types Medicare ('M'), Medicaid ('W'),
Champus ('C'), Tricare ('V'), Medicare Part C ('R'), or Commercial/Other ('O'). Noted next to each modifier are the insurance
types applicable.




                                                                       C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
GENERAL INFORMATION:
                pulled in the order of certain procedure/service has been altered by a particular circumstance, but Master
Modifiers are used to denote that amodifiers listed in the Place of Service Master, Office Location or Transactionnot changed in
respectively. therefore the same codeadds a modifier to a charge, insurance generation (CMS 1500/Prepare EMC) removes
its definition, If the user inadvertently is used and a modifier is added to denote what has been altered. The Transaction Master
those modifiers not allowed per carrier modifier usageand 'AR' are related to from claims for all (CPT) codes with modifiers. F1
(Setup & Support, Option #2) contains type, i.e., 'AQ' information removed billing transaction charges if Insurance type not: 'M'
Help or 'V'.
'C' 'R'at 'Mod Flag' field contains information related to identifiers from the Medicare Physician Fee Schedule Database
(MPFSDB).
CPT Modifiers: 21 - 99 and P1 - P6.

HCPCS Modifiers: all other alphanumeric modifiers except P1 - P6.

Order of Modifiers:
    1     Global or Bundling modifiers (59, 78, 79, 24, 25, etc.)
    2     Payment effectors (22, 52, 53, 26, 50, 51, TC, etc.)
    3     Informational only (LT, RT, T1 - T10, etc.)

Miscellaneous:
2011 CPT Book (Appendix A) & HCPCS Book (Appendix 2) - List of Modifiers
CPT 2010 - Appendix I - Genetic Testing Code Modifiers
Blue Cross Blue Shield Modifier Usage - January 2010
NCC Soft Warnings/Edits
United Healthcare Modifier Policy
For additional carrier specific information, visit the following websites or contact the carrier's customer service/provider relations
department.
  LA Medicare http://www.pinnaclemedicare.com/
  LA Medicaid http://www.lamedicaid.com
  MS\TN Medicare http://www.cahabagba.com
  MS Medicaid http://www.medicaid.ms.gov/



NOTE: Support for all responses/updates scanned to:
  Impact.MD, Documents and Forms-MDS, Type: Grids, Section/Dept: Admin Services, Name: Modifier Grid




                                                                      C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
MODIFIER GRID (Updated: 01/26/11)                                                           See "General Info" tab for explanation of codes used below and links to additional information.

 MODIFIER
                                                                                                                                                                                                                                                                                      CHAMPU




                                                                                 $ IMPACT
                                                                                                                  CPTs UTILIZED                                           MEDICARE (MC)                 RRMC           MEDICAID (WF)                  BLUE CROSS (BC)           AZE             CIG     COV     HUM     TENET     UHC
                                                                                                                                                                                                                                                                                         S




                                                                                            90281–9




                                                                                                                                                                BLAZER




                                                                                                                                                                                                        STATES
                                                                                                                                       D - DME


                                                                                                                                                 O ▪ ASC




                                                                                                                                                                                               PART C
                                                                                            99201 –


                                                                                            00100 –


                                                                                            10021 –


                                                                                            70010 –


                                                                                            80048 –




                                                                                                                                                                 TRAIL-
                                   DESCRIPTION




                                                                                             99499


                                                                                             01999


                                                                                             69999


                                                                                             79999


                                                                                             89399


                                                                                              9200




                                                                                                                                                                                                          ALL
                                                                                               M▪
                                                                                               A▪




                                                                                               R▪
                                                                                               E▪




                                                                                               S▪




                                                                                               L▪
                                                                                                                                                           LA             MS       TN     VA                     LA    MS       TN     VA     LA       MS       TN      VA     ALL      ALL     ALL     ALL     ALL     ALL       ALL




                                                                                                                                                                   S
            Prolonged E&M service (highest level E&M only)
 21*        Eff for DOS prior to 1/1/09
                                                                                 SM            Y                                                           Y      Y        Y        N     Y               Y      Yx              Y     Y      Y         Y        Y       Y               Y       Y                                N

 22*        Increased (unusual) procedural services                              UP                   Y     Y      Y              Y                        Y      Y        Y        Y     Y               Y      **Y             Y     Y      Y         Y        Y       Y       Y       Y       Y                                Y
            Unusual anesthesia – general anesthesia is required when
 23         local or no anesthesia is usually sufficient
                                                                                 PD                   Y                                                    Y      Y        Y        N     Y               Y      Yx     Y        Y     Y      Y         Y        Y       Y               Y       Y                                N

            Unrelated E&M service by the same physician during a post-
 24         op period
                                                                                 PD            Y                                                           Y      Y        Y        Y     N               Y      Y      Y        N     Y      Y         Y        Y       Y               Y       Y                                Y

            Significant separately identifiable E&M service by the same
            physician on the same day of the procedure or other service.
 25         Eff 01/01/2008: For significant, separately identifiable non-
                                                                                 PD            Y                                                  Y        Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y       Y       Y       Y                                Y
            E&M services, see modifier 59.

 26         Professional component                                               DN                         Y      Y        Y     Y                        Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y

 27         Multiple outpatient hospital E&M encounters on the same day          PD                                                               Y        Y      Y        N        N     N              N       Yx              N     N      Y         Y        N      N                N       Y                                N

 32         Mandated services                                                   PD,SM          Y      Y     Y      Y        Y     Y                        Y      Y        Y        N     Y               Y      Yx              Y     Y      Y         Y        Y       Y               Y       Y                                N
 33         Preventataive Service

 47         Anesthesia by a surgeon – not including local anesthesia             UP                         Y               Y     Y                        Y      Y        Y        N     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y

 50         Bilateral procedure                                                  UP                         Y      Y        Y     Y               Y        Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y

            Multiple procedures – modifier should be added to secondary
            or lesser procedure
            Eff 01/01/2009: When multiple procedures other than E&M
            services, physical medicine and rehabilitation services, or
 51         provision of supplies (e.g., vaccines) are performed at the          DN                   Y     Y      !              Y                        Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y
            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 code(s).

 52         Reduced services                                                     DN            N      Y     Y      Y        Y     Y               Y        Y      Y        Y        Y     N               Y      **Y             N     Y      Y         Y        Y       Y               Y       Y                                Y
            Discontinued/terminated procedure – procedure started but
 53         ended prior to completion
                                                                                 DN                   Y     Y      Y        Y     Y                        Y      Y        Y        Y     Y               Y      Yx              Y     Y      Y         Y        Y       Y               Y       Y                                Y

 54         Surgical care only                                                   DN                         Y                                              Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y
 55         Post-operative management only                                       DN                         Y                                              Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y
 56         Pre-operative management only                                        DN                         Y                                              Y      Y        Y        N     N               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y
            Decision for surgery – E&M service provided within 24 hours
                                                                                                                                                                                                                                               Y
 57         of surgery, resulting in initial decision to perform surgery used    PD            Y                                                           Y      Y        Y        Y     Y               Y      Yx     Y        Y     Y
                                                                                                                                                                                                                                            45 days
                                                                                                                                                                                                                                                        Y        Y       Y               Y       Y                                Y
            with major procedure
            Staged (planned) or related procedure or service by same
 58         physician during post-op period
                                                                                 PD                         Y                     Y               Y        Y      Y        Y        Y     Y               Y      Yx     Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y

            Distinct or independent procedures or services not normally
 59         reported together (last resort – use only when no other              PD                   Y     Y      Y        Y     Y               Y        Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y       Y       Y       Y               Y                Y
            appropriate modifier)
 62         Two surgeons -usually with different skills                          DN                         Y      !                                       Y      Y        Y        Y     Y               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y
 63         Procedure performed on infants less than 4 kg                        UP                         Y                                              Y      Y        Y        N     N               Y      Y               N     Y      Y         Y        Y       Y               Y       Y                                Y
            Surgical Team – highly complex procedure requiring multiple
 66         surgical specialties & highly skilled personnel
                                                                                 DN                         Y                                              Y      Y        Y        Y     N               Y      Y      Y        Y     Y      Y         Y        Y       Y               Y       Y                                Y

            Discontinued outpatient hospital/ASC procedure prior to
 73         anesthesia
                                                                                 DN                                                               Y        N      N        Y        Y     N               Y                      N     Y      Y         Y        Y       Y               Y       Y                                N

            Discontinued outpatient hospital/ASC procedure after
 74         anesthesia
                                                                                 DN                                                               Y        N      N        Y        Y     N               Y                      N     Y      Y         Y        Y       Y               Y       Y                                N

            Repeat procedure or service by same physician or non-
 76         physician provider
                                                                                PD,DN                 Y     Y      Y              Y               Y        Y      Y        Y        Y     Y               Y      Yx     N        Y     Y      Y         Y        Y       Y               Y       Y                                Y

            Repeat procedure by a different physician or non-physician
 77         provider, same date of service only
                                                                                 PD                   Y     Y      Y              Y               Y        Y      Y        Y        Y     Y               Y      Yx     N        Y     Y      Y         Y        Y       Y               Y       Y                                Y




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MODIFIER GRID (Updated: 01/26/11)                                                        See "General Info" tab for explanation of codes used below and links to additional information.

 MODIFIER
                                                                                                                                                                                                                                                                             CHAMPU




                                                                              $ IMPACT
                                                                                                               CPTs UTILIZED                                           MEDICARE (MC)                 RRMC          MEDICAID (WF)             BLUE CROSS (BC)           AZE             CIG     COV     HUM     TENET     UHC
                                                                                                                                                                                                                                                                                S




                                                                                         90281–9




                                                                                                                                                             BLAZER




                                                                                                                                                                                                     STATES
                                                                                                                                    D - DME


                                                                                                                                              O ▪ ASC




                                                                                                                                                                                            PART C
                                                                                         99201 –


                                                                                         00100 –


                                                                                         10021 –


                                                                                         70010 –


                                                                                         80048 –




                                                                                                                                                              TRAIL-
                                   DESCRIPTION




                                                                                          99499


                                                                                          01999


                                                                                          69999


                                                                                          79999


                                                                                          89399


                                                                                           9200




                                                                                                                                                                                                       ALL
                                                                                            M▪
                                                                                            A▪




                                                                                            R▪
                                                                                            E▪




                                                                                            S▪




                                                                                            L▪
                                                                                                                                                        LA             MS       TN     VA                     LA   MS       TN     VA   LA    MS       TN      VA     ALL      ALL     ALL     ALL     ALL     ALL       ALL




                                                                                                                                                                S
            Unplanned return to Operating/Procedure room by the same
 78         physician or non-physician provider following initial procedure PD,DN                  Y     Y                     Y               Y        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y
            for related procedure during the post-op period

            Unrelated procedure or service by the same physician during
 79         the post-op period
                                                                              PD                   Y     Y                     Y               Y        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y

            Assistant surgeon (MD use only; non-physician see AS mod
 80         and NPP instructions)
                                                                              DN                         Y                                              Y      Y        Y        Y     Y               Y      Y     Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y

 81         Minimum assistant surgeon (MD use only)                           DN                         Y                                              Y      Y        Y        N     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
            Assistant surgeon when a qualified resident is not available in
 82         a teaching facility (MD use only)
                                                                              DN                         Y                                              Y      Y        Y        N     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y

            MDS Internal modifier ONLY used by BCBSMS for
 85         procedures performed by NPP. BCBSMS internal edits                SM                                                                        N      N        N        N     N    N         N       N     N        N     N    N      Y        N      N        N       N       N       N       N        N       N
            convert AS mod to 85 mod.

            Reference (outside) laboratory – lab tests performed by a lab
 90         other than the referring lab or treating physician
                                                                              SM                                         Y                              Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y

            Repeat clinical diagnostic laboratory test on same day for
 91         patient management purposes
                                                                              PD                                         Y                     Y        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y

 92         Eff 1/1/2008: Alternative laboratory platform testing                                                                                                                                                                       Y      Y                                                                         Y
 99         Multiple modifiers                                                SM                   Y     Y      Y              Y                        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                N

            Documentation of medical reason(s) for not performing the
 1P         PQRI measure i.e., measure not indicated or contraindicated
                                                                              UP                                                                        Y      Y        Y        Y     Y                                                Y      Y                                                                         N

            Documentation of patient reason(s) for not performing to
 2P         PQRI measure i.e., patient declined because of economic,          UP                                                                        Y      Y        Y        Y     Y                                                Y      Y                                                                         N
            religious or social reasons
            Documentation of system reason(s) for not performing to
            PQRI measure i.e., resources not available, insurance
 3P         coverage limits or other reasons attributed to healthcare
                                                                              UP                                                                        Y      Y        Y        Y     Y                                                Y      Y                                                                         N
            system
            Performance measure reporting modifier - action not
 8P         performed, reason not otherwise specified
                                                                              UP                                                                        Y      Y        Y        Y     Y                                                Y      Y                                                                         N

            Anesthesia services professionally furnished by an
 AA         anesthesiologist
                                                                                                                                                        Y      Y        Y        Y     Y              N       Y     Y        Y     N    Y      Y        N      N                N       Y                                Y

            Anesthesia services medically supervised by a physician,
 AD         more than four concurrent procedures
                                                                                                                                                        Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N       Y                                Y

 AF         Specialty Physician                                                                                                                                                                                                                                                                                          N
 AG         Primary Physician                                                                                                                                                                                                                                                                                            N
 AH         Clinical Psychologist                                                                                                                       Y      Y        Y        Y     Y              N       Yx    Y        Y     N    Y      Y        N      N                N       Y                                N
            Principal physician of record
 AI         Eff: 1/1/2010 only for Type M claims
                                                                              SM            Y     N      N      N        N     N    N          N        Y      Y        Y        Y     Y                      N     N        N     N    N      N        N      N        N       N       N       N       N        N       N

 AK         Non participating physician                                       DN                                                                        Y      Y        N        N     N              N       N              N     N    Y      Y        N      N                N       Y                                N
            Physician providing a service in an unlisted Health
 AQ         Professional Shortage Area (HPSA)                                 UP            Y      Y     Y      Y        Y     Y               Y        Y      Y        Y        Y     N    Y         N       Yx    N        N     N    Y      Y        N      N                Y       N                                N
            Eff: 01/01/06
            Physician providing services in a Physician scarcity area
 AR         (PSA) – use with physician services only                          UP            Y      Y     Y      Y        Y     Y               Y        Y      Y        Y        Y     Y              N       Yx    N        Y     N    Y      Y        N      N                Y       N                                N
            Valid for DOS until 06/30/08
            Physician Assistant (PA), Nurse Practitioner (NP), or Clinical
 AS         Nurse Specialist (CNS) for Assistant at Surgery
                                                                              DN                         Y                                              Y      Y        Y        Y     Y               Y      Y              Y     N    Y      Y        N      N        Y       N       Y       Y                        Y

 AT         Acute Treatment - use with CPT 98940, 98941, 98942                                                                                          Y      Y                 Y                            Y                         Y      Y                                                                         N
 AU         Uro, ostomy or trach item                                         DN                                                                        N      N        N        N     N              N       Yx             N     N    Y      Y        N      N                N                                        N
 AV         Item with Prosthetic/orthotic                                     DN                                                                        N      N        N        N     N              N       N              N     N    Y      Y        N      N                N                                        N
            Pysician providing a serivce in a dental health professional
 AZ         shortage area for the purpose of an electronic health record      SM
            incentive payment.




                                                                                                                                                                                                                                                       C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
MODIFIER GRID (Updated: 01/26/11)                                                          See "General Info" tab for explanation of codes used below and links to additional information.

 MODIFIER
                                                                                                                                                                                                                                                                               CHAMPU




                                                                                $ IMPACT
                                                                                                                 CPTs UTILIZED                                           MEDICARE (MC)                 RRMC          MEDICAID (WF)             BLUE CROSS (BC)           AZE             CIG     COV     HUM     TENET     UHC
                                                                                                                                                                                                                                                                                  S




                                                                                           90281–9




                                                                                                                                                               BLAZER




                                                                                                                                                                                                       STATES
                                                                                                                                      D - DME


                                                                                                                                                O ▪ ASC




                                                                                                                                                                                              PART C
                                                                                           99201 –


                                                                                           00100 –


                                                                                           10021 –


                                                                                           70010 –


                                                                                           80048 –




                                                                                                                                                                TRAIL-
                                      DESCRIPTION




                                                                                            99499


                                                                                            01999


                                                                                            69999


                                                                                            79999


                                                                                            89399


                                                                                             9200




                                                                                                                                                                                                         ALL
                                                                                              M▪
                                                                                              A▪




                                                                                              R▪
                                                                                              E▪




                                                                                              S▪




                                                                                              L▪
                                                                                                                                                          LA             MS       TN     VA                     LA   MS       TN     VA   LA    MS       TN      VA     ALL      ALL     ALL     ALL     ALL     ALL       ALL




                                                                                                                                                                  S
            CARRIER USE ONLY - Procedure code change (use when
            the procedure code submitted was changed either for
 CC         administrative reasons or because an incorrect code was
                                                                                SM                                                                        Y      Y        N        N     N              N       N              N     N    Y      Y        N      N                N                                        N
            filed)
            AMCC test has been ordered by an ESRD facility (or MCP
 CD         physician) that is part of the composite rate and is not                                                                                                                                                                                                                                                       N
            separately billable.

            AMCC test has been ordered by an ESRD facility (or MCP
            physician) that is a composite rate test but is beyond the
 CE         normal frequency covered under the rate and is separately
                                                                                                                                                                                                                                                                                                                           N
            reimbursable based on medical necessity

            AMCC test has been ordered by an ESRD facility or MCP
 CF         physician that is not part of the composite rate and is                                                                                                                                                                                                                                                        N
            separately billable
 CG         Policy criteria applied. Eff: 7/1/08                                                                                                          Y      Y        Y        Y     Y              N       N              N     N    Y      Y        N      N                N                                        N
            Catastrophe/Disaster Related
 CR         For DOS eff. 08/21/05; impl 10/03/05
                                                                                                                                                          Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N       Y                                N

            Item or service related, in whole or part, to an illness, injury,
            or condition that was caused by or exacerbated by the
 CS         effects, direct or indirect, or the 2010 oil spill in the Gulf of
            Mexico, including but not limited to subsequent clean up
            activities
 E1         Upper left, eyelid                                                  SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 E2         Lower left, eyelid                                                  SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 E3         Upper right, eyelid                                                 SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 E4         Lower right, eyelid                                                 SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 EA         ESA, anemia, chemo-induced                                                                                                                                                                                                    Y      Y                                                                         N
 EB         ESA, anemia, radio-induced                                                                                                                                                                                                    Y      Y                                                                         N
 EC         ESA, anemia, non-chemo/radio                                                                                                                                                                                                  Y      Y                                                                         N
            Hematocrit greater than 39.0% of hemoglobin greater than
 ED         13.0g/dL for 3 or more consecutive billing cycles immediately                                                                                                                                                                 Y      Y                                                                         N
            prior to and including current billing cycle
            Hematocrit greater than 39.0% of hemoglobin greater than
 EE         13.0g/dL for less than 3 consecutive billing cycles                                                                                                                                                                           Y      Y                                                                         N
            immediately prior to and including current billing cycle
            Service provided as part of Medicaid Early Periodic
 EP         Screening Diagnosis and Treatment Program (EPSDT)
                                                                                                                                                          N      N        N        N     N              N       N     Y        N     N    Y      Y        N      N                N                                        N

            No physician or other licensed health care provider order for
 EY         this item or service
                                                                                                                                       Y                  N      N                                                                        Y      Y                                                                         N

 F1         Left hand, second digit                                             SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F2         Left hand, third digit                                              SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F3         Left hand, fourth digit                                             SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F4         Left hand, fifth digit                                              SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F5         Right hand, thumb                                                   SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F6         Right hand, second digit                                            SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F7         Right hand, third digit                                             SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F8         Right hand, fourth digit                                            SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 F9         Right hand, fifth digit                                             SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 FA         Left hand, thumb                                                    SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
            Item provided without cost to provider, supplier, or
 FB         practitioner in ASC setting
                                                                                                                                                  Y       Y      Y                                                                        Y      Y                                                                         N

            Full or partial credit for replacement devices provided in ASC
 FC         setting
                                                                                                                                                  Y                                                                                       Y      Y                                                                         N

 FP         Services part of Family Planning Program                            SM                                                                                                                                    Y                                                                                                    N

                                                                                                                                                                                                                                                         C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
MODIFIER GRID (Updated: 01/26/11)                                                        See "General Info" tab for explanation of codes used below and links to additional information.

 MODIFIER
                                                                                                                                                                                                                                                                             CHAMPU




                                                                              $ IMPACT
                                                                                                               CPTs UTILIZED                                           MEDICARE (MC)                 RRMC          MEDICAID (WF)             BLUE CROSS (BC)           AZE             CIG     COV     HUM     TENET     UHC
                                                                                                                                                                                                                                                                                S




                                                                                         90281–9




                                                                                                                                                             BLAZER




                                                                                                                                                                                                     STATES
                                                                                                                                    D - DME


                                                                                                                                              O ▪ ASC




                                                                                                                                                                                            PART C
                                                                                         99201 –


                                                                                         00100 –


                                                                                         10021 –


                                                                                         70010 –


                                                                                         80048 –




                                                                                                                                                              TRAIL-
                                  DESCRIPTION




                                                                                          99499


                                                                                          01999


                                                                                          69999


                                                                                          79999


                                                                                          89399


                                                                                           9200




                                                                                                                                                                                                       ALL
                                                                                            M▪
                                                                                            A▪




                                                                                            R▪
                                                                                            E▪




                                                                                            S▪




                                                                                            L▪
                                                                                                                                                        LA             MS       TN     VA                     LA   MS       TN     VA   LA    MS       TN      VA     ALL      ALL     ALL     ALL     ALL     ALL       ALL




                                                                                                                                                                S
            Pregnancy resulted from rape or incest, or pregnancy
 G7         certified by physicians as life threatening
                                                                                                                                                        Y      Y        Y        Y     Y                                                Y      Y                                                                         N

            Monitored Anesthesia care (MAC) for deep, complex,
 G8         complicated, or markedly invasive surgical procedure
                                                                              PD                                                                        Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        Y

            Monitored anesthesia care for patient who has history of
 G9         severe cardio-pulmonary condition
                                                                              PD                                                                        Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        Y

            Waiver of liability statement on file
 GA         Eff 4/1/10: Waiver of Liability Statement issued as required by   PD                                Y        Y     Y                        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y                                        N
            payer policy
            Claim being resubmitted for payment because it is no longer
 GB         covered under a global payment demonstration
                                                                                                                                                        Y      Y        Y        N     Y              N       Yx             Y     N    Y      Y        N      N                N                                        N

            Performed in part by a resident under the direction of a
 GC         teaching physician
                                                                                            Y      Y     Y                                              Y      Y        Y        Y     Y              N       Yx    Y        Y     N    Y      Y        N      N                N                                        Y

            Units of service exceed MUE value but represent medically
 GD         necessary services
                                                                                                                                                                                                                                        Y      Y                                                                         N

            Performance and payment of screening and diagnostic
 GG         mammogram on same patient, same day
                                                                              PD                                Y                                       Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y       Y       Y       N       Y       Y        N       N

            Diagnostic mammogram converted from screening
 GH         mammogram on same day for DOS prior to 1/1/02
                                                                                                                                                        Y      Y        Y        N     N               Y      N              N     Y    Y      Y        Y       Y               Y                                        N

            Actual item/service ordered by physician, item associated
 GK         with GA or GZ modifier
                                                                                                                                                        Y      Y                                                    Y                   Y      Y                                                                         N

            Medically Unnecessary upgrade provided instead of standard
 GL         item, no charge, no ABN
                                                                                                                                                        Y      Y                                                                        Y      Y                                                                         N

            Service delivered personally by a physical therapist or under
 GP         an outpatient physical therapy plan of care
                                                                                                                                                        Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        Y

            Providing visits through asynchronous telecommunications
 GQ         system
                                                                                                                                                        Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        Y

            Providing visits through the use of interactive audio and video
 GT         telecommunications system
                                                                                                                                                        Y      Y        Y        Y     Y              N       Y     Y        Y     N    Y      Y        N      N                N                                        Y

            Attending physician not employed or paid under arrangement
 GV         by the patient‘s hospice provider
                                                                                                                                                        Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        N

 GW         Service not related to the hospice patient‘s terminal condition                                                                             Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        N

            Eff 4/1/10: Notice of Liability issued, Voluntary under payer
 GX         policy
                                                                                                                                                                                                                                                                                                                         N

            Item or service statutorily excluded or does not meet the
 GY         definition of any Medicare benefit. Revised 1/1/08
                                                                                                                                                        Y      Y        Y        Y     Y              N       Yx    Y        Y     N    Y      Y        N      N                N                                        N

            Item or service expected to be denied as not reasonable and
 GZ         necessary
                                                                                                                                                        Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        N

 HA         Child/adolescent program                                                                                                                    N      N        N        N     N              N       N     Y        N     N    Y      Y        N      N                N                                        N

            Competitive Acquisition Program (CAP), no-pay submission
 J1         for a prescription number                                                                                                                   Y      Y        Y        Y     Y                                                Y      Y                                                                         N
            Program suspended 1/1/09 pending new drug contractor

            Competitive Acquisition Program (CAP), restocking of
 J2         emergency drugs after emergency administration                                                                                              Y      Y        Y        Y     Y                                                Y      Y                                                                         N
            Program suspended 1/1/09 pending new drug contractor

            Competitive Acquisition Program (CAP), drug not available
            through CAP as written, reimbursed under average sales
 J3         price (ASP) methodology
                                                                                                                                                        Y      Y        Y        Y     Y                                                Y      Y                                                                         N
            Program suspended 1/1/09 pending new drug contractor

 JC         Skin substitute used as a graft                                                                                                                                                                                                                                                                              N
 JD         Skin substitute not used as a graft                                                                                                                                                                                                                                                                          N

            Drug Amount Discarded/Not Administered
 JW         Program suspended 1/1/09 pending new drug contractor
                                                                                                                                                        Y      Y        Y        Y     Y                                                Y      Y                                                                         N




                                                                                                                                                                                                                                                       C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
MODIFIER GRID (Updated: 01/26/11)                                                         See "General Info" tab for explanation of codes used below and links to additional information.

 MODIFIER
                                                                                                                                                                                                                                                                              CHAMPU




                                                                               $ IMPACT
                                                                                                                CPTs UTILIZED                                           MEDICARE (MC)                 RRMC          MEDICAID (WF)             BLUE CROSS (BC)           AZE             CIG     COV     HUM     TENET     UHC
                                                                                                                                                                                                                                                                                 S




                                                                                          90281–9




                                                                                                                                                              BLAZER




                                                                                                                                                                                                      STATES
                                                                                                                                     D - DME


                                                                                                                                               O ▪ ASC




                                                                                                                                                                                             PART C
                                                                                          99201 –


                                                                                          00100 –


                                                                                          10021 –


                                                                                          70010 –


                                                                                          80048 –




                                                                                                                                                               TRAIL-
                                   DESCRIPTION




                                                                                           99499


                                                                                           01999


                                                                                           69999


                                                                                           79999


                                                                                           89399


                                                                                            9200




                                                                                                                                                                                                        ALL
                                                                                             M▪
                                                                                             A▪




                                                                                             R▪
                                                                                             E▪




                                                                                             S▪




                                                                                             L▪
                                                                                                                                                         LA             MS       TN     VA                     LA   MS       TN     VA   LA    MS       TN      VA     ALL      ALL     ALL     ALL     ALL     ALL       ALL




                                                                                                                                                                 S
            DMEPOS item subject to DMEPOS competitive bidding
 KG         program number 1                                                                                                         Y                                                                                                   Y      Y                                                                         N
            Eff: 7/1/07
            DMEPOS item subject to DMEPOS competitive bidding
 KK         program number 2                                                                                                         Y                   Y      Y                                                                        Y      Y                                                                         N
            Eff: 7/1/07
            DMEPOS item delivered via mail
 KL         Eff: 7/1/07
                                                                                                                                     Y                                                                                                   Y      Y                                                                         N

            Beneficiary resides in a competitive bidding area and travels
            outside that competitive bidding area and receives a
 KT         competitive bid item
                                                                                                                                     Y                                                                                                   Y      Y                                                                         N
            Eff: 7/1/07
            DMEPOS item subject to DMEPOS competitive bidding
 KU         program number 3                                                                                                         Y                                                                                                   Y      Y                                                                         N
            Eff: 7/1/07

            Requirements specified in the medical policy have been met
 KX         Revised 7/1/07; Valid for DOS through 12/31/09
                                                                                                                                                         Y      Y        Y        Y     Y              N       Yx             N     N    Y      Y        N      N                N                                        N

 LC         Left circumflex, coronary artery                                   SM                         Y                     Y                        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y
 LD         Left anterior descending coronary artery                           SM                         Y                     Y                        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y
            Left side (used to identify procedures performed on the left
 LT         side of the body)
                                                                               SM                         Y      Y                                       Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y

            Medicare Secondary Payer for providers who bill for drugs
 M2         under the Competitive Acquisition Program (CAP)
                                                                                                                                                         Y      Y        Y        Y     Y                                                Y      Y                                                                         N

            USER DEFINED: used to flag multiple procedures that
 MP         should use half the assigned RVU value

            Six-month maintenance and servicing fee for reasonable and
 MS         necessary parts and labor which are not covered under any                                                                Y                   N      N        N        N     N              N       N              N     N    Y      Y        N      N                N                                        Y
            manufacturer or supplier warranty

 NU         New Equipment                                                                                                            Y                   N      N        N        N     N              N       N     Y        N     N    Y      Y        N      N                N                                        Y
 P1         A normal healthy patient                                           SM                   Y                                                    Y      Y        N        N     N               Y      Yx             N     Y    Y      Y        Y       Y               Y       Y                                Y
 P2         A patient with mild systemic disease                               SM                   Y                                                    Y      Y        N        N     N               Y      Yx             N     Y    Y      Y        Y       Y               Y       Y                                Y
 P3         A patient with severe systemic disease                             UP                   Y                                                    Y      Y        N        N     N               Y      Yx             N     Y    Y      Y        Y       Y               Y       Y                                Y
            A patient with severe systemic disease that is a constant
 P4         threat to life
                                                                               UP                   Y                                                    Y      Y        N        N     N               Y      Yx             N     Y    Y      Y        Y       Y               Y       Y                                Y

            A moribund patient who is not expected to survive without the
 P5         operation
                                                                               UP                   Y                                                    Y      Y        N        N     N               Y      Yx             N     Y    Y      Y        Y       Y               Y       Y                                Y

            A declared brain-dead patient whose organs are being
 P6         removed for donor purposes
                                                                               SM                   Y                                                    Y      Y        N        N     N               Y      Yx             N     Y    Y      Y        Y       Y               Y       Y                                Y

 PA         Surgery performed on the wrong body part                                                      Y                                                                                                                                                                                                               N
 PB         Surgery performed on the wrong patient                                                        Y                                                                                                                                                                                                               N
 PC         Wrong surgery performed on patient                                                            Y                                                                                                                                                                                                               N
 PI         PET Tumor initial treatment strategy                                                                                                         Y      Y                                                                                                                                                         N
 PS         PET or PET/CT                                                                                                                                Y      Y                                                                                                                                                         N

            Extension of Waiver of Deductible to Services Furnished in
 PT         Connection with or in Relation to a Colorectal Screening Test
            that Becomes Diagnostic or Therapeutic

            Investigational clinical service provided in a clinical research
 Q0         study that is in an approved clinical research study.                                                                                        Y      Y                                                                        Y      Y                                                                         N
            Replaces QA and QR.

            Routine clinical service provided in a clinical research study
 Q1         that is in an approved clinical research study. Replaces QV.
                                                                                                                                                         Y      Y                                                                        Y      Y                                                                         N

            Service for referring/ordering physician qualifies as a service
 Q4         exemption
                                                                                                                                                         Y      Y                                              N                         Y      Y                                                                         N



                                                                                                                                                                                                                                                        C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
MODIFIER GRID (Updated: 01/26/11)                                                       See "General Info" tab for explanation of codes used below and links to additional information.

 MODIFIER
                                                                                                                                                                                                                                                                            CHAMPU




                                                                             $ IMPACT
                                                                                                              CPTs UTILIZED                                           MEDICARE (MC)                 RRMC          MEDICAID (WF)             BLUE CROSS (BC)           AZE             CIG     COV     HUM     TENET     UHC
                                                                                                                                                                                                                                                                               S




                                                                                        90281–9




                                                                                                                                                            BLAZER




                                                                                                                                                                                                    STATES
                                                                                                                                   D - DME


                                                                                                                                             O ▪ ASC




                                                                                                                                                                                           PART C
                                                                                        99201 –


                                                                                        00100 –


                                                                                        10021 –


                                                                                        70010 –


                                                                                        80048 –




                                                                                                                                                             TRAIL-
                                       DESCRIPTION




                                                                                         99499


                                                                                         01999


                                                                                         69999


                                                                                         79999


                                                                                         89399


                                                                                          9200




                                                                                                                                                                                                      ALL
                                                                                           M▪
                                                                                           A▪




                                                                                           R▪
                                                                                           E▪




                                                                                           S▪




                                                                                           L▪
                                                                                                                                                       LA             MS       TN     VA                     LA   MS       TN     VA   LA    MS       TN      VA     ALL      ALL     ALL     ALL     ALL     ALL       ALL




                                                                                                                                                               S
            Service furnished by substitute physician under reciprocal
 Q5         billing arrangement
                                                                             PD            Y      Y     Y      Y        Y     Y               Y        Y      Y        Y        Y     Y              N       Y     Y        Y     N    Y      Y        N      N                N                                        N

            Service furnished by locum tenens physician (not to exceed
 Q6         60 consecutive days)
                                                                             PD            Y      Y     Y      Y        Y     Y               Y        Y      Y        Y        Y     Y              N       Y     Y        Y     N    Y      Y        N      N                N                                        N

 Q9         1 Class B & 2 Class C findings                                                                                                             Y      Y        Y        Y     Y              N       Yx             Y     N    Y      Y        N      N                N                                        N
            FDA investigational device exemption; Investigational
 QA         devices and/or services incident to the use of such devices.                                                                               Y      Y                                                                                                                                                         N
            Expires 12/31/07.
            Physician providing service in a rural HPSA – use with prof
 QB         component only                                                   UP            Y      Y     Y      Y        Y     Y               Y        Y      Y        Y        Y     Y              N       Yx    N        Y     N                    N      N                N                                        N
            Valid for DOS prior to 01/01/06
            Medical direction of two, three or four concurrent anesthesia
 QK         procedures involving qualified practitioners
                                                                                                                                                       Y      Y        Y        Y     Y              N       Y              Y     N    Y      Y        N      N                N       Y                                Y

            Documentation on file showing lab test(s) was ordered
            individually or ordered as a CPT recognized panel other than
 QP         automated profile codes 80002-80019, G0058, G0059,
                                                                                                                                                       Y      Y        Y        N     Y              N       Yx             Y     N    Y      Y        N      N                N                                        N
            G0060.
            Item or service provided as part of a (Medicare qualifying)
 QR         clinical trial. Expires 12/31/07.
                                                                                                                                                       Y      Y        Y        N     Y              N       Yx             Y     N                    N      N                N                                        N

            Monitored Anesthesia care (can be billed by a CRNA or
 QS         physician)
                                                                                                                                                       Y      Y        Y        Y     Y              N       Y              Y     N    Y      Y        N      N                N                                        Y

            Urban HPSA – use with prof component only
 QU         Valid for DOS prior to 01/01/06
                                                                             UP            Y      Y     Y      Y        Y     Y               Y        Y      Y        Y        N     Y              N       Yx    N        Y     N                    N      N                N                                        N

            Item or service provided as routine care in a Medicare
 QV         qualifying clinical trial. Expires 12/31/07.
                                                                                                                                                       Y      Y        N        N     N              N       N              N     N                    N      N                N                                        N

 QW         CLIA waived test                                                 PD                                         Y                              Y      Y        Y        Y     Y              N       Y     Y        Y     N    Y      Y        N      N                N                                        N
            CRNA service with medical direction by a physician (used
 QX         with QY)
                                                                             DN                                                                        Y      Y        Y        Y     Y              N       Y     Y        Y     N    Y      Y        N      N                N       Y                                Y

            Medical direction of one CRNA by an anesthesiologist (used
 QY         with QX)
                                                                             DN                                                                        Y      Y        Y        Y     Y              N       Y     N        Y     N    Y      Y        N      N                N       Y                                Y

 QZ         CRNA without medical direction by a physician                    SM                                                                        Y      Y        Y        Y     Y              N       Y     Y        Y     N    Y      Y        N      N                N       Y                                Y
 RC         Right coronary artery                                            SM                         Y                     Y                        Y      Y        Y        Y     Y               Y      Yx             Y     Y    Y      Y        Y       Y               Y       Y                                Y
 RR         Rental                                                                                                                 Y                   N      N        N        N     N              N       N     Y        N     N    Y      Y        N      N                N                                        Y
            Right side (used to identify procedures performed on the right
 RT         side of the body)
                                                                             SM                         Y      Y                                       Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y

            Nurse Practitioner rendering service in collaboration with a
 SA         physician
                                                                             DN            Y                                  Y                        N      N        N        N     N              N       N     N        N     N    Y      Y        N      N                N       Y       Y                        N

            Medically Necessary Service or Supply - documentation
 SC         attached
                                                                                                                                                       N      N        Y        N     N               Y      N     Y        N     N    Y      Y        N      N                N                                        N

            Ambulatory surgical center (ASC) facility care
 SG         Valid for DOS prior to 1/1/08
                                                                                                                                              Y        N      N        N        N     N              N       N              Y     N    Y      Y        N      N                N       Y                                N

 SL         State supplied vaccine                                                                                                                                                                                                                                                     Y                                N
 ST         Related to trauma or injury                                                                                                                N      N        N        N     N              N       N              N     N    Y      Y        N      N                N                                        N
 T1         Left foot, second digit                                          SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T2         Left foot, third digit                                           SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T3         Left foot, fourth digit                                          SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T4         Left foot, fifth digit                                           SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T5         Right foot, great toe                                            SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T6         Right foot, second digit                                         SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T7         Right foot, third digit                                          SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T8         Right foot, fourth digit                                         SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 T9         Right foot, fifth digit                                          SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 TA         Left foot, great toe                                             SM                         Y                                              Y      Y        Y        Y     Y               Y      Yx    Y        Y     Y    Y      Y        Y       Y               Y       Y                                Y
 TC         Technical Component                                              DN                         Y      Y        Y     Y                        Y      Y        Y        Y     Y              N       Yx    Y        Y     N    Y      Y        N      N                N       Y                                Y
 TD         Used to report services performed by an RN                                                                                                 N      N        N        N     N              N       N              N     N    Y      Y        N      N                N                                        N
 TG         Complex/high level care                                                                                                                    N      N        N        N     N              N       N     Y        N     N    Y      Y        N      N                N                                        N

                                                                                                                                                                                                                                                      C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
MODIFIER GRID (Updated: 01/26/11)                                                   See "General Info" tab for explanation of codes used below and links to additional information.

 MODIFIER
                                                                                                                                                                                                                                                                        CHAMPU




                                                                         $ IMPACT
                                                                                                          CPTs UTILIZED                                           MEDICARE (MC)                 RRMC          MEDICAID (WF)             BLUE CROSS (BC)           AZE             CIG     COV     HUM     TENET     UHC
                                                                                                                                                                                                                                                                           S




                                                                                    90281–9




                                                                                                                                                        BLAZER




                                                                                                                                                                                                STATES
                                                                                                                               D - DME


                                                                                                                                         O ▪ ASC




                                                                                                                                                                                       PART C
                                                                                    99201 –


                                                                                    00100 –


                                                                                    10021 –


                                                                                    70010 –


                                                                                    80048 –




                                                                                                                                                         TRAIL-
                                  DESCRIPTION




                                                                                     99499


                                                                                     01999


                                                                                     69999


                                                                                     79999


                                                                                     89399


                                                                                      9200




                                                                                                                                                                                                  ALL
                                                                                       M▪
                                                                                       A▪




                                                                                       R▪
                                                                                       E▪




                                                                                       S▪




                                                                                       L▪
                                                                                                                                                   LA             MS       TN     VA                     LA   MS       TN     VA   LA    MS       TN      VA     ALL      ALL     ALL     ALL     ALL     ALL       ALL




                                                                                                                                                           S
 TH         Obstetrical treatment/service, prenatal or postpartum                                                                                  N      N        N        N     N              N       Y     Y        Y     N    Y      Y        N      N                N                                        N
 TS         Follow-up service                                                                                                                      N      N                                                                        Y      Y                                                                         N
 TV         Holiday/Weekend payment rate                                                                                                           N      N        N        N     N              N       N              N     N    Y      Y        N      N                N                                        N
 UC         Medicaid level of care 12, as defined by each state                                                                                    N      N        N        N     N              N       Y              N     N    Y      Y        N      N                N                                        N
            Patient cannot tolerate oral medication and/or transdermal
 Y6         delivery system                                                                                                                        Y      Y        N        N     N              N       Yx             N     N                    N      N                N                                        N
            NOTE: Presume retired - no listing available
            The medication was given for an acute condition
 Y7         NOTE: Presume retired - No listing available
                                                                                                                                                   Y      Y        N        N     N              N       Yx             N     N                    N      N                N                                        N

            The patient was having severe pain
 Y8         NOTE: Presume retired - no listing available
                                                                                                                                                   Y      Y        N        N     N              N       Yx             N     N                    N      N                N                                        N

            Oral medications and/or transdermal delivery system were
 Y9         ineffective.                                                                                                                           Y      Y        N        N     N              N       Yx             N     N                    N      N                N                                        N
            NOTE: Presume retired - no listing available
OTHERS      Other Modifiers not listed above




                                                                                                                                                                                                                                                  C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
    Cell: R3
Comment: RRMC ALL:
          RRMC recognizes only national modifiers. Claims with Local Carrier modifiers will be denied.


    Cell: U3
Comment: TN WF:
          Accepts same mods as TN MC.


    Cell: W3
Comment: BCBSLA:
          Accepts all valid CPT and HCPCS modifiers.


    Cell: X3
Comment: BCBSMS accepts all modifiers listed in the current CPT book.




                                                                                                         C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls
OTHER MODIFIERS NOT LISTED
 A1   Dressing for one wound
 A2   Dressing for 2 wounds
 A3   Dressing for 3 wounds
 A4   Dressing for 4 wounds
 A5   Dressing for 5 wounds
 A6   Dressing for 6 wounds
 A7   Dressing for 7 wounds
 A8   Dressing for 8 wounds
 A9   Dressing for 9 or more wounds
 AE   Registered dietician
 AJ   Clinical Social Worker
 AM   Physician, team member service
 AP   Determination of refractive state was not performed in the course of diagnostic ophthalmological
      examination
 AW   Item furnished in conjunction with a surgical dressing
 AX   Item furnished in conjunction with dialysis services
 AY   Item or service furnished to an ESRD patient that is not for the treatment of ESRD
 BA   Item furnished in conjunction with parenteral enternal nutrition (PEN) services
 BL   Special acquisition of blood and blood products
 BO   Orally administered nutrition, not by feeding tube
 BP   The beneficiary has been informed of the purchase and rental options and has elected to
      purchase the item
 BR   The beneficiary has been informed of the purchase and rental options and has elected to rent
      the item
 BU   The beneficiary has been informed of the purchase and rental options and after 30 days has not
      informed the supplier of his/her decision
 CA   Procedure payable only in the inpatient setting when performed emergently on an outpatient who
      expires prior to admission
 CB   Service ordered by a renal dialysis facility (RDF) physician as part of the ESRD beneficiary‘s
      dialysis benefit
      Not part of the composite rate
      Separately reimbursable
 DA   Oral health assessment by a licensed health professional other than a dentist
 EJ   Subsequent claims for a defined course of therapy, e.g., EOP, Sodium Hyaluronate, infiximab.

 EM   Emergency reserve supply (for ESRD benefit only)
 ET   Emergency services
 G1   Most recent URR reading of less than 60
 G2   Most recent URR reading of 60 to 64.9
 G3   Most recent URR reading of 65 to 69.9
 G4   Most recent URR reading of 70 to 74.9
 G5   Most recent URR reading of 75 or greater
 G6   ESRD patient for whom less than 6 dialysis sessions have been provided in a month
 GE   This service has been performed by a resident without the presence of a teaching physician
      under the primary care exception
 GF   Non physician (e.g., nurse practitioner (NP), certified registered nurse anesthetist (CRNA),
      certified registered nurse (CRN), clinical nurse specialist (CNS), physician assistant (PA))
      services in a critical access hospital
 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



                                            C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsOther Mods
GO   GO Service delivered personally by an occupational therapist or under an outpatient
     occupational therapy plan of care




                                           C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsOther Mods
AMBULANCE MODIFIERS
  D   Diagnostic or Therapeutic site other than ―P‖ or ―H‖ when these are used as origin codes
      (treatment facility)
  E   Residential, domiciliary, custodial facility (other than a 1819 facility) (Nursing Home)
  G   Hospital-based dialysis facility (hospital or hospital-related)
  H   Hospital
  I   Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
  J   Non-hospital based dialysis facility (free-standing)
  N   Skilled Nursing Facility (SNF, 1819 facility, ECF)
  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 a physician‘s office enroute to the hospital (includes
      HMO nonhospital facility, clinic, etc.)




                                         C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsAmbulance Mods
MODIFIER ##
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)




                                       C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsTemplate
MODIFIER 21
05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 22
05/20/10   United Modifer Policy

03/31/10   Myth 2: If CPT doesn‘t include a code for a service you provided, you can append modifier 22 or
           modifier 52 to a different code.
           Reality: Using modifier 22 (Increased procedural services) or 52 (Reduced services) instead of
           an unlisted procedure code is a big mistake. Some coders go this route when physicians provide
           new technology because they realize the payer must manually review such claims and the
           carrier‘s computer cannot automatically deny them. But you could be setting your practice up for
           accusations of incorrect coding and problematic RVUs for a new code when one is finally
           assigned. If no precise code exists, you should report the service using the appropriate unlisted
           procedure or service code. Plus: If you are coding for a new technology where you have no code
           to describe what the doctor is doing, you should be using an unlisted code. This way, when CPT
           advisors develop a new code, they will approve new relative value units (RVUs) as well. If you
           use an established CPT code with modifier 22 or 52 for the new technology, then RVUs will be
           stolen from the established CPT code to fund the new code. That is detrimental to the specialty.
           (Excerpt: Part B News Insider, Vol. 11, No. 3)

01/26/10   CPT 2010, Appendix A

01/26/10   The role of the -22 modifier is to reflect additional work that is not typically part of a particular
           procedure but does not qualify for its own procedure code. Surgeries for which services
           performed are significantly greater than usually required may be billed for additional
           reimbursement with the -22 modifier added to the CPT code for the procedure. Billing of the -22
           modifier will generate an ADR (additional documentation request) and the claim will be referred
           to Medical Review. Modifier -22 should only be reported with procedure codes that have a global
           period of 0, 10, or 90 days. (LA Medicare Medguide, Surgery)


12/22/09   On list of Nationally Accepted Medicare Mods;
           Use only in conjunction with surgical procedure codes
           Submit operative report and/or a written detailed description with the initial claim

12/22/09   Per Ingenix 2007 CPT Expert:
           When the service(s) provided is greater than that usually required for the listed procedure, it may
           be identified by adding modifier 22 to the usual procedure number. A report may also be
           appropriate.

12/22/09   Effective 1/1/2008: Description will be changed to "Increased procedural services." Physician's
           work must be "substantially greater than typically required", but "substantially greater" has not
           been defined. Not to be used on E&M services.

12/22/09   AMA Guideline:
           1. Increased time resulting from extra work by physician such as significant scarring.
           2. Extensive trauma that complicates a procedure and cannot be coded with additional codes
           3. Morbid obesity involving extra time
           4. Excessive blood loss
           5. Post radiation therapy
           6. Excessive time for adhesions
           7. Prior surgery infections
           8. Maybe used with the following codes: Anesthesia, Surgery, Radiology, Pathology and Lab,
           Medicine
12/22/09   CMS Guideline: Medicare Carrier Manual indicates that the relative value units represent the
           average work and practice expense involved in a particular code. So payment for a service may
           be increased or decreased only under unusual circumstances. Requires submission of
           documentation to support the unusual circumstance.

12/22/09   With exception of BCBSMS, carriers allow an additional 25% reimbursement. BCBSMS allows
           only 20% eff 1/1/09.

12/22/09   Claims with mod 22 should be filed hard copy when allowed with notes attached to support
           additional reimbursement.

12/22/09   For carriers that require EMC (MC, BCBSMS), must file EMC then wait for denial or payment at
           unmodified rate, then pursue additional payment via appeal with comment 02R22.


12/22/09   Some experts suggest only using modifier 22 if procedure takes twice as long as normal. Don't
           use an unlisted procedure code when modifier 22 could be used instead. If possible, use a
           more specific code instead of a modifier.

12/22/09   See specific carriers for info on restrictions.

05/01/09   On nationally accepted list of Medicare Modifiers

01/01/09   Part B Insider, Vol. 9, No. 4 & Coding Answer Book, 01-2009

01/01/09   TN MC:No standard reimbursement.
           Evaluated on a case by case basis according to documentation provided.
           Include a brief description of what made the procedure "increased" in Item 19 of the CMS1500
           form or the electronic notepad.

01/01/09   MS MC:Valid for codes with GSP of 0, 10 or 90 days. Not valid for GSP of "XXX", including
           E&M, Radiology, Laboratory, Pathology and most medicine codes.

01/01/09   Trailblazers: Requires op report and a separte concise statement about how the service differs
           from the usual. This modifier should only be reported with procedure codes that have a GPS of
           0, 10 or 90 days.

01/01/09   LA MC: Pays an additional 15% up to limiting charge

01/01/09   LA WF: Pays 125% of fee on file.
           Cannot be used on lab codes or visits.
           Multiple births same delivery method
           System auto-prints to paper.
           Eff mid 2008, mod 22 can be billed with mod 26.

01/01/09   VA WF: Use to ensure review of attached documentation.
01/01/09   LA BC:Payment of an additional 15-20% will be considered for minor additional circumstances;
           25% additional will be considered for very unusual additional circumstances.
           When using modifier -22 (increased procedural service), attach to the claim form a medical or
           operative report and an explanation of why the modifier is being submitted or copies of
           applicable medical records.
           Without this information, the modifier will not be recognized and the standard allowable charge
           will be applied without review or consideration of the modfiier. It is not appropriate to bill modifier -
           22 for an office visit, X-ray, lab or evaluation and management services.


01/01/09   MS BC: Pays at 120% of allowable
MODIFIER 23
01/26/10   CPT 2010, Appendix A

01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Coverage/payment "by report" basis Anesthesia by surgeon is not covered

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 24
05/20/10   United Modifer Policy

03/31/10   Myth 1: Modifier 24 Will Lead to Medicare Payment for Postop Complications. If a patient has a
           postoperative complication, some practices bill the complication treatment with modifier 24
           (Unrelated evaluation and management service by the same physician during a postoperative
           period) appended.
           Reality: You should not use this modifier for Medicare patients‘ Complications, experts say.
           ―Medicare does not pay for complications. Medicare considers complications to be part of the
           global, even though CPT considers postoperative complications separately billable,‖ says
           Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare
           Solutions. According to Medicare, the only time you can collect from Part B for the treatment of
           a complication is if that complication requires a return to the operating room. ―And in those cases
           you should use modifier 78 (Unplanned return to the operating/ procedure room by the same
           physician following initial procedure for a related procedure during the postoperative period),‖
           Cobuzzi explains. ―Unlike the AMA definition, which says Complications are not part of the
           global, Medicare says complication care is part of the global and is not billable unless it involves
           a return to the OR,‖ Cobuzzi says. (Excerpt: Part B News Insider, Vol. 11, No. 3)


01/26/10   CPT 2010, Appendix A

01/26/10   Use to report an unrelated E&M service, by the same physician, during a postoperative
           period. The -24 modifier is added to the appropriate level of E&M service (i.e., visit
           code). Services submitted with the -24 modifier must be sufficiently documented to establish
           that the visit was unrelated to the surgery. (LA Medicare Medguide, Surgery)


01/26/10   A physician, who is responsible for the post-operative care and has reported and been
           paid through the use of modifier -55, should also use modifier -24 to report any unrelated visits.
           (LA Medicare Medguide, Surgery)

01/10/10   Focus is on Dx. Cannot use if same Dx for services in a GSP. May require notes/explanation
           on claim submission.

01/10/10   On list of Nationally Accepted Medicare Mods; hints for use:
           - Should only be used by the surgeon for an E&M service rendered during the post-op period
           that is totally unrelated to the procedure previously performed
           - Use only with E&M services

01/10/10   Per Ingenix 2007 CPT Expert:
           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 level of E/M service.


01/10/10   AMA Guideline:
           1. Only used with E/M codes.
           2. ICD-9-CM coding is critical to support.
           3. May be used to indicate that a physician provides a surgical service to a patient and during the
           postoperative period of the surgery, provides an E/M service for a different problem.
01/10/10   CMS Guideline:
           Medicare Carrier Manual indicates that an E/M service submitted with modifier 24 must have
           sufficient documentation to support the service being billed.

10/18/09   Medicare will pay for both critical care and a global fee if the provider uses codes 99291 and
           99292 with modifier 25 or 24 and submits documentation that the critical care was unrelated to
           the specific anatomic injury or general surgical procedure performed; acceptable documentation
           includes an ICD9 code in the range of 800.0-959.9 (except 930-939) which clearly indicates the
           critical care was unrelated to the surgery (LA Medicare Medguide, Surgery)


10/18/09   LA WF: Effective 01/2007, if used on straight WF claims, it will be ignored, not denied.

10/18/09   LA BC: Pays separate allowable charge. Additional documentation required.

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Should only be used by the surgeon for an E&M service rendered during the postoperative
           period that is totally unrelated to the procedure previously performed
           Use only with E&M services

06/12/06   LA MC Modifier 24 Flowchart
MODIFIER 25
05/20/10   BCBS MS Modifier 25 Policy

05/20/10   United Modifer Policy (011707)

03/31/10   Perform the sharpie test before adding an E&M: strike out all documentation for E&M related to
           the procedure, if what is left is still significant, separately identifiable, then ok to use (Excerpt
           from 13th Annual Compliance Seminar - Pain Booklet)

03/01/10   Coding Institue articles -
           Do Your Services Warrant Use of Modifier 25?
           Check these Quiz Answers to Determine Whether You're Using Modifier 25 Properly
           Use this sample appeal letter as Ammo in Your Fight Against Modifier 25 Denials

03/01/10   Office of Inspector General's Draft Report - Use of Modifier 25, Letter from Mark McClellan, MD
           to Daniel Levinson, OIG

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   A significant, separately identifiable E&M service, by the same physician, on the day of a
           procedure. This should be billed with the appropriate E&M procedure code with the -25 modifier.
           This indicates that the patient's condition required a significant, separately identifiable E&M
           service above and beyond the usual pre-operative and post-operative care associated with the
           procedure or service that was performed. (LA Medicare Medguide, Surgery)


01/10/10   UNITED: Not acceptable on CPT 99211.

01/10/10   Different Dx are not required for reporting of the E&M services on the same date as a procedure
           with a GSP.

01/10/10   Not called the 'decision for surgery' modifier, however it can be used as 'decision for surgery'
           modifier for minor procedures that are unscheduled.

01/10/10   Can be used with the same Dx if the physician indicates. MDS cannot automatically add this
           modifier without the physician's OK unless it is a different Dx. If different Dx, must RQ/tab to
           office to OK addition of modifier if same Dx was used.

01/10/10   On list of Nationally Accepted Medicare Mods
           Used by the surgeon on the E&M code for a service performed on the same day as but not
           related to a surgical procedure
           Use only with E&M services
           Can be used to override column 2 CCI edits.
01/10/10   Per Ingenix 2007 CPT Expert:
           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. A significant, separately
           identifiable E/M service is defined or substantiated by documentation that satisfies the relevant
           criteria for the respective E/M services to be reported. The E/M service may be prompted by the
           symptom or condition for which the procedure and/or service was provided. As such, differing
           diagnoses are not required for reporting of the 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.

01/10/10   AMA Guidelines:
           1. CPT guidelines do NOT require a separate diagnosis for the E/M service and the
           procedure/other service performed.
           2. No restrictions to any level of E/M's.
           3. Not recognized by all payors
           4. Documentation - key

01/10/10   CMS Guidelines:
           1. Modifier 25 to be used for minor procedure
           2. With procedure of 10 day global as the decision for surgery
           3. Can be utilized for the following services: 99201-99499; 92002-92014; G0101-G0175

01/10/10   Use of Modifier 25 with CPT 99211:
           Some carriers do not pay when 99211 is billed with modifier 25, i.e., this very low service level
           does not meet the requirement for 'Significant' as defined by CPT; i.e., UHC if done in
           conjunction with procedure for injection. Recommend CPT 90772 for administration of injection.


01/10/10   TN MC: 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 the E&M services on the same date. Not used to report and E&M service that
           resulted in decision to perform surgery - see modifier 57.

01/10/10   MS MC: Procedure and E&M must occur on same day by same provider.
           Use with procedures with 0 or 10 day GSP.
           Do not use when lab or X-ray services are the only other services performed.
           Use for established patients only for a new illness or follow up visit with multiple complaints.


09/22/09   United Health Care does not allow 99211 with modifier 25.

10/18/09   Medicare will pay for both critical care and a global fee if the provider uses codes 99291 and
           99292 with modifier 25 or 24 and submits documentation that the critical care was unrelated to
           the specific anatomic injury or general surgical procedure performed; acceptable documentation
           includes an ICD9 code in the range of 800.0-959.9 (except 930-939) which clearly indicates the
           critical care was unrelated to the surgery (LA Medicare Medguide, Surgery)


05/01/09   On nationally accepted list of Medicare Modifiers
05/01/09   Used by the surgeon one the E&M code for a service performed on the same day as but not
           related to a surgical procedure
           Use only with E&M services

01/14/08   Aetna Modifier 25 Support

04/17/07   5 Steps Let You Soar to Modifier 25 Success

04/17/07   LA WF: Effective 01/2007, if used on straight WF claims, it will be ignored, not denied.

04/17/07   LA BC: Pays separate allowable charge. Additional documentation required.

04/17/07   AETNA: Eff 010107: Radiologists billing E&M must use mod 25.
MODIFIER 26
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   LA BC: Pays professional component of the allowable charge.

01/01/10   LA WF: Professional portion only of a procedure that typically consists of both a professional and
           a technical component (e.g., interpretation of laboratory or x-ray procedures performed by
           another provider) Pays 40% of the fee on file. Any CPT w/ mod 26 is not eligible for mod 22 per
           email from FR Q&A LA MEDICAID FOLDER

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 27
01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)
MODIFIER 32
01/26/10   CPT 2010, Appendix A

01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Great tool for trackingclaims that require payment from other sources

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 33
01/25/11   New CPT Modifier for Preventive Services, AMA Article




                                                       C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xls33
MODIFIER 47
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Can be used by delivering physician (maternity)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 50
01/11/11   When loading RVUs, if modifier 50 use 1.5 times unmodified CPT RVU respective to FAC -
           0622, NONFAC - 0623, and WRK RVU - 0626

05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/26/10   Where the procedure code does not specifically state bilateral, but is an "approved" bilateral
           procedure code, use the proper CPT procedure code with the -50 modifier. Payment for the
           bilateral procedure is based on the lower of the actual charge or 150 percent of the fee
           schedule. (LA Medicare Medguide, Surgery)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Use only with surgery codes identified by CMS as bilateral procedures
           Bill on one line (i.e., 15822-50) instead of two lines (i.e., 15822, 15822-50)

01/10/10   See Medicare Fee Schedule Database Appendix B

01/10/10   Should be used for some ophthalmology diagnostic tests (92225-92235)

01/10/10   Payment based on 150% of fee schedule

01/10/10   Use one line item with # of services "1"

12/16/09   LA Medicaid - Modifier 50 must be before modifier 51 if reported on same charge

12/16/09   LA MC: If billing facet joint injections (incl CPT 64470, 64472, 64475 and 64476 on both sides,
           must use 50 mod.

12/16/09   TN MC: Pays at 150% of MPFSDB for procedure/service.

12/16/09   MS BC: Pays at 100% for 1st line, 50% for 2nd line

12/16/09   LA BC: Payment based on 150% of allowable charge for applicable codes.

12/16/09   VA WF: Per Audrey, notes are not required.

06/19/09   LA BCBS Modifier 50 Policy

05/01/09   On nationally accepted list of Medicare Modifiers

03/19/09   MS WF: Pays at 100% for first procedure and 50% for second procedure. Typically billed as one
           line item, one unit with 50 modifier. If bilateral procedure is secondary, use modifier 51, do not
           quantitize. Per April 3/19/09, send notes on first submission even though they might not be
           required.

03/16/09   LA WF: Attach supporting documentation; bill on a single line with 1 unit. Pays at 150% of the
           fee on file. System auto-prints to paper.
09/01/08   MS WF Bilateral Procedure

03/06/08   MS BCBS Modifier 50 Policy

06/12/06   LA MC Modifier 50 Flowchart
MODIFIER 51
01/17/11   The following F10 command will start a special Charge Application Report that removes RVU‘s
           associated with charges that have a specific Modifier. When choosing to use this F10
           command, simply hit the F10 key, type in the command, and then follow the standard Charge
           Application Report wizard. Below is a description of the F10 command and what it eliminates.

           DZ167M51 will remove all RVU‘s associated with charges that have a Modifier = 51.


05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix E - Summary of CPT Codes Exempt from Modifier 51

01/26/10   CPT 2010, Appendix A

01/26/10   When billing, report the major surgical procedure without the multiple procedure modifier -51.
           To decide which surgical procedure is primary, the surgeon should first look at the fee schedule
           amounts of each procedure. The procedure with the highest allowable amount is the primary
           procedure. The procedures should then be ranked in fee schedule amount order, from highest to
           lowest. Report additional surgical procedures performed by the same surgeon on the same day
           with modifier -51 if the multiple surgery indicator is a "2." (LA Medicare Medguide, Surgery)



01/26/10   Modifier -51 is automatically generated by Medicare system when the multiple surgery rules
           apply and prompts our computer system to apply the multiple surgery reduction. Therefore, it is
           not necessary for providers to submit modifier -51 on claims for multiple surgery procedures. (LA
           Medicare Medguide, Surgery)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Hints for use:
           Use when more than one surgical procedure is performed
           Use on the secondary procedure

01/10/10   Not to be used with "add-on" codes

01/10/10   Per MC, not requried for billing purposes. The carrier will assign the 51 modifier as appropriate
           based on the services billed.

01/10/10   AMA Guidelines:
           1. Modifier 51 may be used to identify multiple medical procedures performed at the same
           session, a combination of medical and surgical services, or several procedures performed at the
           same operative session by the same physician.
           2. Modifier 51 not for codes designated as "add-on" codes (+ symbol)
           3. Modifier 51 not for codes designated as "51 exempt" (Æ symbol)

01/10/10   CMS Guidelines:
           1. Payment policy is based on the lesser of the actual charge or 100% of the fee schedule for
           the primary procedure, the lesser of the actual charge or 50% of the fee schedule for the second
           through fifth procedure.
           2. After the fifth procedure is based on "per report" basis for pricing.
01/10/10   LA MC: Medicare system automatically applies modifier 51 during the adjudication process. It
           does not need to be added to the secondary procedure

01/10/10   VA MC: The Medicare system will insert the 51 modifier and the provider should never use this
           modifier for billing purposes.

01/10/10   TN MC: Not required for billing purposes. The carrier will assign the 51 modifier as appropriate
           based on the services billed.

01/10/10   TN MC: Do not append to designated "add-on" codes.

01/10/10   TN MC: The allowed amount is 100% of the fee schedule amount for the highest value
           procedure, 50% of the fee schedule amount for the 2nd through 5th procedures, and "by report"
           for subsequent procedures provided to the same patient on the same day.

01/10/10   MS MC: Not required for billing. The carrier will assign the multiple procedure modifier if
           appropriate based on the services billed.

01/10/10   LA WF: Attach supporting documentation; use the modifier on all procedures except the primary
           one. Not accepted on add-on codes. Send with notes instead of using mod 59.
           Pays at 100% of the fee on file for primary; 50% of the fee on file for all others Multiple births
           different delivery methods Assistant surgeons are not required to use the 51 modifier for
           secondary procedures. System auto-prints to paper.

01/10/10   MS WF: Bilateral procedures performed secondary to another procedure will each be paid at
           50%. If CPT code not designated as bilateral and if secondary procedure, use 51 and bill 2 units.
           If CPT code is designated as bilateral and if secondary procedure, use 51 and one unit.
           Per April 3/19/09, send notes on first submission even though they might not be required.

01/10/10   VA WF: Per Audrey, notes are not required.

01/10/10   LA BC: Generally pays primary or highest allowable procedure at 100% of allowable charge and
           rest at 50% of allowable charge.

05/01/09   On nationally accepted list of Medicare Modifiers

09/19/08   MS WF Bilateral Policy

01/23/08   MS BCBS Modifier 51 Policy
MODIFIER 52
06/01/10   OBGYN Coding Alert, Vol 13, No 4 - Check Descriptor for Unilateral, Bilateral Before Appendind
           Modifier 52
           Excerpt: Overapplying mod 52 may mean you are cutting out ethical reimbursment your
           physician deserves…if code descriptors indicate 'unilateral or bilateral' you would not add
           modifier 52, the 'unilateral' takes care of that...along the same lines you might argue that codes
           with words such as 'tube(s)' instead of 'tubes' might represent a unilateral or bilateral procedure
           as well.

05/20/10   United Health Care - Modifer Policy

03/31/10   Myth 2: If CPT doesn‘t include a code for a service you provided, you can append modifier 22 or
           modifier 52 to a different code.
           Reality: Using modifier 22 (Increased procedural services) or 52 (Reduced services) instead of
           an unlisted procedure code is a big mistake. Some coders go this route when physicians provide
           new technology because they realize the payer must manually review such claims and the
           carrier‘s computer cannot automatically deny them. But you could be setting your practice up for
           accusations of incorrect coding and problematic RVUs for a new code when one is finally
           assigned. If no precise code exists, you should report the service using the appropriate unlisted
           procedure or service code. Plus: If you are coding for a new technology where you have no code
           to describe what the doctor is doing, you should be using an unlisted code. This way, when CPT
           advisors develop a new code, they will approve new relative value units (RVUs) as well. If you
           use an established CPT code with modifier 22 or 52 for the new technology, then RVUs will be
           stolen from the established CPT code to fund the new code. That is detrimental to the specialty.
           (Excerpt: Part B News Insider, Vol. 11, No. 3)

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   In maternity cases, can be used by delivering physician or anesthesiologist.

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Use when less than the full service is performed (the submitted amount should be reduced
           accordingly)
           Should be supported by documentation and a brief statement of explanation to clarify the
           reduction.

01/10/10   AMA Guideline:
           1. To be used when a procedure is started, but not finished (discontinued).
           2. May not be used to indicate that a procedure was electively ccancelled before the induction of
           anesthesia and/or preparation in the operating suite for surgery.

01/10/10   CMS Guideline:
           1. Should be added when the service or procedure s significantly less than usually required.
           2. Medicare does not recognize the modifier 52 with E/M services.
           3. CMS will ignore the modifier 52 when added to a code unless documentation (operative note,
           medical record, chart note) and a provider statement as to the reduction of the service is
           attached with the claim.
01/10/10   For ASC - can be used for services that do not require anesthesia and are partially completed or
           discontinues at the physician's discretion. In the ASC, charges will be paid at 50% of the fee
           schedule rate.

01/01/10   Trailblazers: Surgical Procedures: An op report and a concise statement as to how the services
           performed differs from the usual are required for surgical procedures.

01/01/10   Trailblazers: Non-Surgical Procedures: Provide a concise statement as to how the service
           performed differs from the usual in the comment field of the electronic claim; a separate
           attachment is not required.

01/01/10   TN MC: Frequently misused. The proper use of modifier 52 is to report that a service was not
           completed or some part of a multiple part service was not performed. A fee reduction may be in
           order as well; however that is not the primary purpose of this modifier.

01/01/10   TN MC: Providers using this modifier should include a brief description of what portion of the
           service was completed in Item 19 of the CMS1500 or the electronic notepad. Documentation
           must be submitted on request.

01/01/10   MS MC: Eff 010107-requires documentation supporting usage;
           Do not use for E&M services

01/01/10   LA WF: Attach supporting documentation. Pays at 75% of the fee on file.

01/01/10   LA BC: Payment reduced by 20%.

01/01/10   MS BC: Pays at 50% of allowable

01/01/10   UNITED: Pays at 50% of allowable

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 53
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Attach operative notes to the initial claim
           Claims without proper documentation will be denied and must be resubmitted for payment.

01/10/10   AMA Guidelines:
           1. Due to extenuation circumstances
           2. Situations that threaten the health of a patient - hypotension, crisis, arrhythmia
           3. Not used for elective cancellation of a procedure
           4. Primarily reportedto show a true "surgical hold" due to patient status.
           5. Physician use only

01/10/10   CMS Guidelines:
           1. To assist in communication extenuating circumstances to carriers
           2. Not valid for E/M codes
           3. Not for elective cancellations
           4. Not valid when a procedure is changed or converted to a more extensive procedure.
           5. Many payors will only cover on procedure code

01/01/10   TN MC: Under certain circumstances, a 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.

01/01/10   TN MC: 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.

01/01/10   TN MC: Providers using this modifier should include a brief description of what portion of the
           service was completed in Item 19 of the CMS1500 or the electronic notepad. Documentation
           must be submitted on request.

01/01/10   LA MC: Cannot use for anesthesia. Report minutes only.

01/01/10   MS BC: Pays at 30% of allowable

01/01/10   LA BC: Pays at 50% of allowable charge for applicable codes.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 54
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Use with surgery code to indicate postoperative care was done in part or whole by another
           provider.
           Appropriate for surgery codes only.
           Include coverage for the surgical procedure and the preoperative care.

01/10/10   Only use with codes that carry more than 0 global days

01/10/10   CMS requires a request for transfer be documented in the patient's medical record

10/18/09   If physician relinquishes care the day after surgery to the physician who acted as an assitant at
           surgery, the assistant at surgery who provides the in hospital post operative care should bill
           usign subsequent hospital care codes for the inpatient hospital care and bill teh surgical code
           with modifier 55, the primary surgeon shoudl bill the code for the surgery with modifier 54. (LA
           Medicare Medguide, Post Operative Care by Assistant Surgeons)


07/23/09   CMS document/Part B Q&A regarding Mod 54

07/23/09   TN MC: Payment limited to the amount allotted to the preoperative and intra-operative services
           only.

07/23/09   LA WF: Pays at 70% of the fee on file. NOTE: If full service payment is made for a procedure
           (i.e., the procedure is billed and paid with no modifier), addl payment will not be made for
           surgical care only, preoperative care only or postoperative care only. In order for all providers to
           be paid in the case when modifiers 54, 55, and 56 would be used, each provider must use the
           appropriate modifier to indicate the service performed. Claims that are incorrectly billed and
           paid must be adjusted using the correct modifier in order to allow payment for other claims billed
           with the correct modifier.

07/23/09   MS WF: Pays at 85% of allow

07/23/09   LA BC: Pays at 80% of allowable for applicable codes

07/23/09   MS BC: Pays at 70% of allowable

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 55
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   A physician, who is responsible for the post-operative care and has reported and been
           paid through the use of modifier -55, should also use modifier -24 to report any unrelated visits.
           (LA Medicare Medguide, Surgery)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Use with the surgery code.
           The date of service sould always be the same as the date of the surgery.
           The date the provider assumed and relinquished care should be indicated in Item 19 of
           CMS1500 claim form.
           The total number of days should be indicated in Item 24G of the CMS 1500 claim form.
           Coverage is for the total amount of time the provider is responsible for the postoperative care
           and is not intended to be used only for those times the patient is actually seen in the office.


01/10/10   Do not code for postoperative management until the initial followup period has been completed.


10/18/09   If physician relinquishes care the day after surgery to the physician who acted as an assitant at
           surgery, the assistant at surgery who provides the in hospital post operative care should bill
           usign subsequent hospital care codes for the inpatient hospital care and bill teh surgical code
           with modifier 55, the primary surgeon shoudl bill the code for the surgery with modifier 54. (LA
           Medicare Medguide, Post Operative Care by Assistant Surgeons)


07/23/09   CMS document re Mod 55

07/23/09   LA WF: Pays at 20% of the fee on file. NOTE: If full service payment is made for a procedure
           (i.e., the procedure is billed and paid with no modifier), addl payment will not be made for
           surgical care only, preoperative care only or postoperative care only. In order for all providers to
           be paid in the case when modifiers 54, 55, and 56 would be used, each provider must use the
           appropriated modifier to indicate the service performed. Claims that are incorrectly billed and
           paid must be adjusted using the correct modifier in order to allow payment for other claims billed
           with the correct modifier.

07/23/09   MS WF: Pays at 15% of allow

07/23/09   LA BC: Pays at 20% of allowable charge for applicable codes.

07/23/09   MS BC: Pays at 15% of allowable

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 56
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/01/10   LA WF: 10% of the fee on file. NOTE: If full service payment is made for a procedure (i.e., the
           procedure is billed and paid with no modifier), addl payment will not be made for surgical care
           only, preoperative care only or postoperative care only. In order for all providers to be paid in the
           case when modifiers 54, 55, and 56 would be used, each provider must use the appropriated
           modifier to indicate the service performed. Claims that are incorrectly billed and paid must be
           adjusted using the correct modifier in order to allow payment for other claims billed with the
           correct modifier.

01/01/10   MS WF: Preop management is inclusive in the allowance for surgical care. Surgical codes billed
           with 56 will be denied.

01/01/10   LA BC: Pays at 10% of allowable charge for applicable codes.

01/01/10   MS BC: Pays at 15% of allowable
MODIFIER 57
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   Use to show that the decision for major surgery was made during an E&M
           service either the day before the surgery or the day of surgery. Use only with major surgeries
           (90 day post-operative period). This should be billed with the proper E&M procedure. (LA
           Medicare Medguide, Surgery)


01/10/10   If decision for surgery E&M is performed on the same day, or the day before an unscheduled
           surgery, must append modifier 57 to receive separate payment for the E&M code.


01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Per Ingenix 2007 CPT Expert:
           An evaluation and management service that resulted in the initial decision to perform surgery
           may be identified by adding modifier 57 to the appropriate level of E/M service.

01/10/10   CMS Guidelines:
           1. Use when the initial decision is made to perform a major surgery (one that carries 90 global
           days). The decision must be the day of, or the day before the major surgery.
           2. Should not be used with surgeries that carry either 0 or 10 global days.
           3. No additional documentation is necessary for claim submission.

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Used only on an E&M service performed the day before or on the same day as a major surgical
           procedure

09/12/08   Modifier 57 - Part B Coding Coach

09/12/08   TN MC: Documentation in the patient's medical record should support a significant and
           separately identifiable E&M service from the usual work associated with the preoperative
           surgical work.

09/12/08   LA BC: Pays separate allowable charge

06/12/06   LA MC Modifier 57 Flowchart
MODIFIER 58
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   Use to indicate a staged or related procedure or service by the same physician during the post-
           operative period of the surgery that was: a) planned prospectively at the time of the original
           procedure (staged); b) more extensive than the original procedure; or c) for therapy
           following a diagnostic surgical procedure. Do not use this modifier to report the treatment of a
           problem that requires a return to the operating room. Claims for problems or complications
           following a procedure should be billed with modifier -78. (LA Medicare Medguide, Surgery)


01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Hints for use:
           If the surgeon performs a subsequent surgery related to the original surgery, the surgery may be
           paid separately if it:
                Is a staged procedure
                Is a more extensive procedure than the original
                Involves therapy following a diagnostic surgical procedure
           Can be used to override column 2 CCI edits.
           Starts a new global period
           Used for surgical procedures in a GSP that have their own GSP (CPT 10021-69999)

01/10/10   AMA Guidelines:
           1. Used to show that, after an original procedure a physician, for some reason, is required to
           perform another procedure during the global period.
           2. The reason for the second procedure must fall into one of the following three categories:
              a. Planned prospectively at the time of the original procedure.
              b. More extensive than the original procedure.
              c. Therapeutic following a diagnostic procedure.

01/10/10   CMS Guidelines:
           1. Do not use when return to the OR is required due to a complication - use mod 78.
           2. Used when a diagnostic biopsy results in a major surgery. Append to the major surgery code
           and paid at 100% of the fee schedule.

05/01/09   On nationally accepted list of Medicare Modifiers

01/01/09   MS BCBS: Eff 1/1/09, subject to new coding edits. Providers will receive Msg 318 on EDI Error
           Report requesting medical records. Not all claims will require documentation. Do not send
           unless request is received.

01/01/08   Effective 1/1/2008: Mod 58 will apply to staged or related procedures that were "planned or
           anticipated" at the time of the original surgery, not just ones the physician planned in advance.
           Will be used for surgical procedures, not diagnostic ones.

01/01/08   MS MC: Payment is reduced with this modifier.
01/01/08   TN MC:Failure to use this modifier when appropriate may result in denial of the subsequent
           surgery. Not used to report the treatment of a problem that requires a return to the
           operating/procedure room.

06/12/06   LA MC Modifier 58 Flowchart
MODIFIER 59
05/20/10   Humana Modifier 59 Policy

05/20/10   MS BC Modifier 59 Policy

05/20/10   United Modifer Policy

03/31/10   Myth 3: If you want to separate Correct Coding Initiative (CCI) edit pairs, modifier 59 is the
           modifier to use.
           Reality: Not necessarily. ―First of all, never use modifier 59 (Distinct procedural service) unless
           you can support that the two codes that are normally bundled were done at different encounters
           or on separate sites,‖ Cobuzzi says. ―If you cannot show this in the documentation, the 59
           modifier will not be supported.‖ Plus: You should never use modifier 59 if another modifier (or
           no modifier at all) will tell the story more accurately. CPT guidelines indicate that modifier 59 is
           only appropriate if no more descriptive modifier is available. In some cases, other modifiers
           might be more suited for your situation. For instance, if the physician performs an open
           procedure on the patient‘s third finger and a percutaneous procedure on the patient‘s fourth
           finger, you should append modifier F2 (Left hand, third digit) to 26735, and append modifier F3
           (Left hand, fourth digit) to 26727.
           Because CCI lists the finger modifiers (FA, F1 to F9) as acceptable to use when separating code
           pairs, you should use them instead of modifier 59 in this case. In some cases, however, your
           payer may not accept ―F‖ codes — in that circumstance, you should report modifier 59 instead.
           Bottom line: Only append modifier 59 to a claim if you are certain of the distinct nature of the
           procedures you are reporting, and if no more appropriate modifier exists. (Excerpt: Part B News
           Insider, Vol. 11, No. 3)

02/12/10   Cahaba Correct Usage of Modifier 59

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Hints for use:
           Use when service rendered was distinct or separate from other services performed on the same
           day, i.e., different session, different procedure, different site, separate lesion.
           Use on component procedure
           Only effective in Correct Coding situations
           Must be clearly documented in the record
           Can be used to override column 2 CCI edits.
01/10/10   Per Ingenix 2007 CPT Expert:
           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 no more descriptive modifier is
           available, and the use of modifier 59 best explains the circumstances, should modifier 59 be
           used.

01/10/10   Effective 1/1/2008: Description will be changed from "Physician" to "Individual" and
           "documentation must support" that there was a separate session or distinctive service.

01/10/10   AMA Guideline:
           Use to clearly show instances when distinct and separate multiple procedures/services are
           provided to the same patient on the same day.

01/10/10   CMS Guidelines:
           1. Used when distinct and separate multiple procedures or services are provided to a patient on
           a single date of service.
           2. Developed exclusively to identify procedure or services that are typically not performed
           together.
           3. Can be used to signal to carrier that it was medically necessary to exceed a published
           Medically Unlikely Edit (MUE) for particular service.

01/10/10   Generally does not matter which position 59 modifier is in on claim.

01/10/10   LA WF: Pays fee on file.

01/27/09   Modifier 59 Support

01/27/09   LA MC:
           This is a modifier of last resort
           Quantitize if at all possible
           Use 50 mod if really a bilateral scenario
           Use LT/RT mod if bilateral billed on two lines
           Use 76 mod on Rad/EKGs if same CPT on same date by same provider
           Use F# and T# mods on fingers and toes
           Use RC/LD mods for coronary surgeries where applicable

01/27/09   Can be used on PT codes if allowed in CCI edits

01/27/09   Cannot be used with J codes

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Use when service rendered was distinct or separte from other services performed on the same
           day: different session, different porcedure, different site, separte lesion
           Use on component procedure
           Only effective in Correct Coding situations
           Must be clearly documented in the record
01/10/09   LA BC: Pays separately except for BCBSLA edits (see attached file). This modifier should not be
           used to bypass an edit unless the proper criteria for its use are met and documentation in the
           patient's medical record clearly supports this criteria and the use of modifier 59. Modifier 59
           should not be appended to an E&M service. To report a separate and distinct E&M service with
           a non-E&M service performed on the same date, see modifier 25. Nerve blocks performed for
           postop pain management, providedthat they are not the mode of anesthesia and are distinct
           procedures, are eligible for reimbursement when identified by the 59 modifier as a distinct
           procedure.

01/10/09   MS BCBS: Eff 1/1/09, subject to new coding edits. Providers will receive Msg 318 on EDI Error
           Report requesting medical records. Not all claims will require documentation. Do not send
           unless request is received.

11/18/08   LA BC Modifier 59 Edits

01/14/08   Aetna Modifier 59 Policy

02/10/07   AETNA: Eff 021007: no additional reim made for the following procedures when billed in
           combination with other procedures, even if mod 59 is used: Lysis of adhesions, diagnostic
           proctoscopy, sigmoidoscopy removal polyp by snare, proctoscopy, diagnostic laparoscopy,
           insertion of cervical dilator, application of cast

06/12/06   LA MC Modifier 59 Flowchart
MODIFIER 62
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   lf two surgeons (each in a different specialty) are required to perform a specific procedure, each
           surgeon bills for the procedure with a modifier -62. Co-surgery also refers to the surgical
           procedures involving two surgeons performing the parts of a procedure simultaneously, i.e.,
           aminectomy spinal fusion or bilateral knee replacements. Documentation of the medical
           necessity for two surgeons is required for certain services. (LA Medicare Medguide, Surgery)


01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Hints for use:
           The surgeons must have different specialties or documentation must be available to verify the
           necessity for two surgeons of the same specialty.
           An assistant at surgery may not be billed when co-surgeons are billed.

01/10/10   Both surgeons should bill for the actual procedure with the 62 modifier, plus they should each bill
           separately for the work they did other than the co-surgery procedure without the 62 modifier.
           Don't use the modifier 62 on all the codes on the claims.
           If one of the physicians forgets his 62 modifier and submits his claim first, it will be paid at full
           allow and the other physician's claim will be denied.

01/10/10   AMA Guidelines:
           1. To be used when the additional surgeon is not acting as an assistant, but performing a distinct
           portion of the procedure.
           2. Should be used only when co-surgery is required due to:
              a. the complexity of the procedure
              b. the patient's condition
              c. or both.

01/10/10   CMS Guidelines:
           1. Rules for use of modifier 62 can be found in the Medicare Carriers Manual section 4820-4828
           and 15044-15046.
           2. May be used if 2 surgeons are performing parts of a single procedure identified by one
           procedure code.
           3. May be used if 2 surgeons are performing the same or similar procedure in separate body
           areas.
           4. May be used if 2 surgeons are performing components of a related procedure(s) generally
           performed by the same surgeon.

01/10/10   LA MC: Cannot be used in combination with 80, 81, 82 or AS. Pays 62.5% of allow to each co-
           surgeon.

01/10/10   LA Medicare Modifier 62 flowchart

01/10/10   MS MC: Pays 62.5% of allow to each co-surgeon.

01/10/10   TN MC: Pays 62.5% of allow to each co-surgeon.

01/10/10   VA MC: Pays 62.5% of allow to each co-surgeon.
01/10/10   LA WF: Attach supporting documentation which clearly indicates the name of each surgeon and
           the procedures performed by each. Pays at 80% of the fee on file.

01/10/10   MS WF: Pays at 62.5% of allow.

01/10/10   LA BC: If allowed, pays at 120% of allowable divided by both surgeons

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 63
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix F - Summary of CPT Codes Exempt from Modifier 63

01/26/10   CPT 2010, Appendix A

01/10/10   AMA Guidelines:
           1. Only used in the surgery section of the CPT book.
           2. Only used on invasive surgical procedures.
           3. May not be used on surgical procedures generally for correction of congenital anomalies.
           This is due to those procedures already include the additional work complexity inherently in
           those CPT codes.

01/10/10   Modifier 63 should not be appended to any CPT codes listed in the E&M Services, Anesthesia,
           Radiology, Pathology/Laboratory or Medicine sections.

01/10/10   LA WF: Attach supporting documentation if multiple modifiers are used (ie., 51 and 63). Pays at
           125% of the fee on file

01/10/10   UNITED: Pays an additional 20%
MODIFIER 66
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a
           specific procedure, each surgeon bills for the procedure with a modifier -66. There must
           sufficient documentation to support that a team was medically necessary. Operative notes
           must be submitted with the claim. (LA Medicare Medguide, Surgery)

01/10/10   AMA Guidelines:
           May be used when more than 2 surgeons are required to perfom a major service.
           Examples include:
           33945 - Heart transplant
           32851 - Lung transplant, single; without cardiopulmonary bypass
           32854 - Lung transplat, double; with cardiopulmonary bypass
           50320 - Donor nephrectomy, open form living donor

01/10/10   CMSA Guidelines:
           1. Guidelines for surgical team are found in section 15046 of the Medicare Carriers Manual.
           2. Reimbursement for team surgery is made on the basis of general reasonable charge criteria
           consistent with reimbursement in that service area. Each piece is looked at and priced
           individually.
           3. A report must be submitted with each claim to show the portion of the procedure in which the
           submitting physician was involved


01/10/10   LA MC: Cannot be used in combination with 80, 81, 82 or AS.

01/10/10   LA WF: Attach supporting documentation which clearly indicates the name of each surgeon and
           the procedures performed by each. Pays at 80% of the fee on file.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 73
01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 74
01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 76
05/20/11   Per Glenda Thornton, LA MC:
           Our interpretation of Modifier 76- a repeated procedure by the same
           physician on the same date, on the same patient, same exact body site.
           All of the listed criteria must be met before modifier 76 can be used.

01/25/11   Per Part B Insider, Vol 12, No. 3 - Modifier updated to add or non-physician provider to
           description.

05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Not to be used for E&M codes

01/10/10   Can be used for X-rays and injections

01/10/10   AMA Guideline:
           To be intended for use to show the same procedure or service was repeated, rather than the
           same procedure being performed at multiple sites.

01/10/10   CMS Guidelines:
           1. Examples of repeat procedures include:
              Followup X-rays
              Repeat EKGs
              Repeat laboratory services
           2. Need clear indication of medical necessity
           3. Performed for comparative purposes
           4. Two services performed at different times
           5. For follow-up after treatment of intervention
           6. Repeat a test at different intervals
           7. Can be used to signal to carrier that it was medically necessary to exceed a published
           Medically Unlikely Edit (MUE) for particular service.

01/10/10   Accepted by Wellcare PFFS

10/18/09   Used to show a repeat procedure done on the same day by the same physician (LA Medicare
           Medguide, Surgery)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 77
01/25/11   Per Part B Insider, Vol 12, No. 3 - Modifier updated to add or non-physician provider to
           description.

05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Not to be used for E&M codes

01/10/10   Can be used for X-rays and injections

01/10/10   Bill CPT code describing procedure performed during return trip

01/10/10   Payment limited to intra-operative services only

01/10/10   AMA Guideline:
           To be intended for use to show the same procedure or service was repeated, rather than the
           same procedure being performed at multiple sites.

01/10/10   CMS Guidelines:
           1. Examples of repeat procedures include:
              Followup X-rays
              Repeat EKGs
              Repeat laboratory services
           2. Need clear indication of medical necessity
           3. Performed for comparative purposes
           4. Two services performed at different times
           5. For follow-up after treatment of intervention
           6. Repeat a test at different intervals
           7. Can be used to signal to carrier that it was medically necessary to exceed a published
           Medically Unlikely Edit (MUE) for particular service.

01/10/10   SEG: Recognized 77 mod on appeal.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 78
01/25/11   Per Part B Insider, Vol 12, No. 3 - Modifier updated to add or non-physician provider to
           description.

05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   Claims for problems or complications following a procedure should be billed with modifier -78.
           (LA Medicare Medguide, Surgery)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Hints for use:
           - Use only if another CPT with GSP is related to complications of the previous procedure i.e.,
           returning patient to OR for repair of complication from first surgery, use -78 on CPT code of
           second surgery.
           - Use only when procedures are performed in an operating room, cardiac catheterization suite,
           laser suite, or endoscopy suite by the same physician as the first procedure.
           - Use on surgical procedures only.
           - Does not start a new global period.
           - Can be used to override column 2 CCI edits.

01/10/10   Effective 1/1/2008: Description will be changed to:
           "Unplanned return to the operating/procedure room by the same physician following initial
           procedure for a related procedure during the postoperative period."

01/10/10   AMA Guidelines:
           1. For complications that require the patient to be taken back to the operating room.
           2. May be used on unlisted code for the related procedure that requires the return to the
           operating room.
           3. NOT for use with codes that state, "subsequent, related or redo" in the code descriptor.

01/10/10   CMS Guidelines:
           1. For use on related procedures performed the same day or during the global period for
           procedures that carry more than 0 global days.
           2. For use in reporting complications arising from a previous surgery during the global period
           that requires a return to the operating room.

10/18/09   Used when the surgeon who performed the initial procedure must return to the operating room
           to perform a related procedure or treat a complication during the post operative period.
           Reimbursement for procedures billed with modifier 78 is limited to the intraoperative percentage
           for the procedure. Procedrues are not subject to multiple surgery rules. (LA Medicare Medguide,
           Surgery)

01/10/10   CPT 10021-69999 78: Used for surgical procedures in a GSP that have their own GSP
01/10/10   TN MC: The provider may need 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. Payment is limited to
           the amount allotted for the intra-operative services only. Failure to use this modifier when
           appropriate may result in denial of the subsequent surgery.


01/10/10   LA Medicare Modifier 78 flowchart

01/10/10   UNITED: Pays at 84% of allowable

01/10/10   LA BC: Pays at 80% of allowable charge for applicable codes.

01/10/10   MS BCBS: Eff 1/1/09, subject to new coding edits. Providers will receive Msg 318 on EDI Error
           Report requesting medical records. Not all claims will require documentation. Do not send
           unless request is received.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 79
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   Submit modifier -79 when the physician who performed the initial global surgery
           procedure performs an unrelated surgical procedure during the post-operative period after the
           original procedure. (LA Medicare Medguide, Surgery)


01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Hints for use:
           - Use only when to procedure performed is unrelated to the previous procedure.
           - Use on surgical procedures performed by the same physician only.
           - Starts a new global period.
           - Can be used to override column 2 CCI edits.

01/10/10   CMS Guidelines:
           1. Documentation of different diagnosis codes is usually sufficient to show procedure was
           unrelated.
           2. Section 4824 of the Medicare Carrier's Manual has further reference on unrelated procedures.


01/10/10   CPT 10021-69999 79: Used for surgical procedures in a GSP that have their own GSP

01/10/10   LA Medicare Modifier 79 flowchart

03/16/09   Modifier 79 Support

01/01/09   MS BCBS: Eff 1/1/09, subject to new coding edits. Providers will receive Msg 318 on EDI Error
           Report requesting medical records. Not all claims will require documentation. Do not send
           unless request is received.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 80
01/11/11   When loading RVUs, if modifier 80 use 16% of unmodified CPT RVU respective to FAC - 0622,
           NONFAC - 0623, and WRK RVU - 0626

05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

06/17/11   BCBSMS: Modifier 80 Policy

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Use for assistant surgeon services rendered by a qualified physician in a non-teaching facility.
           Allowable for MDs and/or DOs only.
           The same doctor cannot bill as the surgion and as the assistant surgeon


01/10/10   LA MC: Cannot be used in combination with 62 or 66. Pays 16% of MPFSDB

01/10/10   TN MC: Pays at 16% of the fee schedule for the surgical procedure

01/10/10   LA WF: MD's: Pays at 20% of the full service physician fee on file for MDs. Certified Nurse
           Midwives: Pays at 80% of MD's 'Assistant Surgeon' fee. Assistant surgeons should always
           append an 80 modifier on each claim line.

01/10/10   LA Medicare Modifier 80 flowchart

01/10/10   UNITED: Pays at 16% of allowable

01/10/10   LA BC: Do not bill with AS. Pays at 20% of allowable for applicable codes.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 81
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Not to be used for services performed by PAs or RNs.
           Use for minimal assistant surgeon services rendered by a qualified physician in a non-teaching
           facility.

01/10/10   LA MC: Cannot be used in combination with 62 or 66.

01/10/10   UNITED: Pays at 16% of allowable

01/10/10   LA BC: Do not bill with AS. Pays at 20% of allowable for applicable codes.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 82
05/20/10   United Modifer Policy

01/26/10   CPT 2010, Appendix A

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Used for MD and/or DO only

01/10/10   LA MC: Cannot be used in combination with 62 or 66.

01/10/10   UNITED: Pays at 16% of allowable

01/10/10   LA BC: Do not bill with AS. Pays at 20% of allowable for applicable codes.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 85
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER 90
01/26/10   CPT 2010, Appendix A

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Labs bill carrier in their state for tests performed by a reference lab.
           See CR3090 2/26/04

01/10/10   Independent labs, specialty 69
           Not valid for anatomic pathology paid via fee schedule
           Drawing fee G0001 cannot be referenced
           The CLIA # of billing lab and performing lab (reference) must be different - ANSI edit
           Paper and NSF must not bill modifier 90 and non modifier 90 services on the same claim

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Item 20 of the CMS 1500 claim form should be checked 'yes' and the purchase price of the test
           must be indicated
           The NPI number of the referring lab must appear in Item 32

06/28/07   Medicare Claims Processing Manual - Lab services
MODIFIER 91
01/26/10   CPT 2010, Appendix A

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Hints for use:
           - Can be used to override column 2 CCI edits.
           - Use for multiple or subsequent results, not to confirm initial results
           - Not for testing problems with specimens or equipment

01/10/10   CMS Guideline:
           1. Can be used to signal to carrier that it was medically necessary to exceed a published
           Medically Unlikely Edit (MUE) for particular service.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER 92
01/26/10   CPT 2010, Appendix A

01/10/10   Per CPT:
           Used when a lab service is done with a kit containing a single use, disposable chamber. "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."
MODIFIER 99
01/26/10   CPT 2010, Appendix A

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Use only when more than four modifiers are necessary per line item.
           Use box 19 of the CMS 1500 claim form to enter all of the applicable modifiers for paper claims.
           Use the Documentation Record to enter all of the applicable modifiers for electronic claims.



05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER AA
01/25/10   Use modifier AA when the anesthesiologist is working alone (Anesthesia & Pain Coders Pink
           Sheet, January 2010)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Stand alone mod

01/10/10   Affects payment

01/10/10   LA BC: Pays at 100% of allowable charge

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER AD
01/25/10   When anesthesiologist becoems involved in directing more than four cases, medical directing
           becomes medical supervision. Use the AD modifier for the supervising anesthesiologist.
           Payment is calculated by allocating three base units for each procedure performed, mulitplied by
           the local conversion factor. Also add one unit when the anesthesiologist documents he was
           present for induction. (Anesthesia & Pain Coders Pink Sheet, January 2010)


01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Allow 3 base units

01/01/10   Affects payment

01/01/10   Additional time may be recognized if documentation supports

01/01/10   LA BC: Pays at medically supervised rate: 4 base units of the applicable anesthesia conversion
           factor

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER AF
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER AG
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER AH
01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER AI
08/09/10   Modifier AI Fact Sheet

03/31/10   Excerpt from 13th annual compliance seminar - pain booklet: Outside the context of telehelath
           services, physicians will bill an initial hospital care or initial nursing facility care code for their first
           visit during a patient's admission to the hospital or nursing facility in lieu of the consultation
           codes these physicians may have previously reported. An NPP, who is enrolled in the Medicare
           program, is permitted to report the initial hospital care visit or new patient office visit, as
           appropriate, under current medicare policy.
           Because of an existing CPT coding rule and current Medicare payment policy regarding the
           admitting physician, we will create a modifier to identify the admitting physician of record for
           hospital inpatient and nursing facility admissions. For operational purposes, this modifier will
           distinguish the admitting physician of record who oversees the patient's care from other
           physicians who may be furnishing specialty care.
           The admitting physician of record will be required to append the specific modifier to the initial
           hospital care or initial nursing facility care code which will identify him/her as the admitting
           physician of record who is overseeing the patients care. Subsequent care visits by all physicians
           adn qualified NPPs will be reported as subsequent hospital care codes and subsequent nursing
           facility care codes. To be consistent with OPPS policy, as noted above, we will pay only new
           and established office or other clinic visits under teh PFS.

02/15/10   Part B Insider, Vol. 11, No. 6 - Forget to Append Modifier AI to Inpaitent Hospital Visit Claim?
           This MAC will Still Reimburse You

01/26/10   Added 2010 (Medicare HCPCS 2010 Additions, December 2009)

01/25/10   Added 2010, attending physician of record is suppose to apply to initial inpatient hospital care
           (99221-99223) claims (Medical Practice Coding Pro, January 2010, Vol. 16, No. 1)

12/08/09   •For Medicare beneficiaries, append modifier AI to the initial hospital care code (99221–99223)
           or initial nursing facility care code (99304–99306) reported by the attending physician.
           •Only the admitting physician of record who oversees the patient‘s care reports modifier AI.
           •It is inappropriate for consulting physicians to report modifier AI with their initial hospital care
           code.
           •Do not append modifier AI to subsequent hospital care codes (99231–99233) or inpatient
           consultation codes (99251–99255).
           (http://www.shopingenix.com/CodingCentralArticles/?id=197)
MODIFIER AK
01/01/10   LA BC: Pays at 85% of allowable
MODIFIER AQ
01/10/10   10% bonus paid to physicians rendering service in HPSA area. See HPSA 2006 Primary Care
           ZIP code list. In most cases, physicians who render service in one of these ZIP codes will
           automatically be paid a bonus. If ZIP code is not listed, go to
           www.cms.hhs.gov/hpsaphysicianbonuses and click on the "Carrier Web Sites" link. If service
           was performed in a qualified area, file with mod AQ.

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   LA MC: Need to add to claim; will be valid through 2009

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Use only for professional services rendered by a physician

02/07/09   Modifier AQ support

01/01/06   Became effective
MODIFIER AR
01/10/10   5% bonus for physicians in PSA. In most cases, physician will automatically be paid for services
           rendered in one of the ZIP codes on the PSA Primary Care or PSA Specialty Care Zip Code
           List. For services rendered in ZIP codes not on the list, consult the Primary Care/Specialty
           Counties listing and use the AR modifier to receive the PSA bonus.


01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   LA MC: Do not need to add-automatically paid if applicable

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Use only for professional services rendered by a physician

02/01/00   Medicare HPSA article
MODIFIER AS
06/17/11   BCBSMS: Modifer AS Guidelines

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Typically used on PA charge when billed with employer's Physician Code.

01/10/10   LA MC: Cannot be used in combination with 62 or 66.

01/10/10   TN MC: Pays at 16% of 85% of the physician fee schedule for the surgical procedure.

01/10/10   LA WF: Pays at 80% of MD's 'Assistant Surgeon' fee

05/01/09   On nationally accepted list of Medicare Modifiers

03/24/09   AS modifier must be in first position on Medicare cliams (per RA on paid claims)

03/24/09   LA BC: Do not bill with 80, 81 or 82. Pays at 85% of assistant surgeon allowable for applicable
           codes.

01/01/07   AETNA: Eff 010107: NPP paid at 12% of surgical fee when eligible.

01/01/07   UNITED: Paid at 14% of allowable

01/01/07   CIGNA: Pays at 13.6% of fee schedule
MODIFIER AT
05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER AU
01/10/10   LA BC: Pays at 85% of allowable
MODIFIER AV
01/10/10   LA BC: Pays at 85% of allowable
MODIFIER AZ
12/08/10   effective 01/01/2011

12/08/10   See MLN Matters: MM7035




                                     C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsAZ
MODIFIER CC
12/08/10   Procedure code change - used by carrier to indicate that the procedure code submitted was
           changed either for administrative reasons or because an incorrect code was filed. No effect on
           payment. Payment determination will be based on the new code used by carrier.
MODIFIER CD
10/30/09   Medlearn Matters MM6683
MODIFIER CE
10/30/09   Medlearn Matters MM6683
MODIFIER CF
10/30/09   Medlearn Matters MM6683
MODIFIER CG
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER CR
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   Used to facilitate claims processing and track services provided to victims of disasters (LA
           Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Effective 8/31/09 CR mod is andatory for applicable HCPCS codes on any claim for which
           Medicare Pt B payment is conditioned directly or indirectly on the presence of a "formal waiver"
           (waiver of a program requirement that otherwise would apply to the statute or regulation).


05/01/09   On nationally accepted list of Medicare Modifiers

09/23/05   Modifier CR support

08/21/05   Became effective
MODIFIER CS
01/17/11   effective 01/01/11, retroactive to 04/20/10

01/14/11   Medlearn Matters 7087 - Modifer and Condition Code for BP Oil Spill Claims




                                                         C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsCS
MODIFIER E1
04/27/10   Per LA WF Claim Check & Clear Claim Connection Orientation Presentation:
           Site Specific Modifier accepted by LA WF, must be in 1st position

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/01/10   On list of Nationally Accepted Medicare Mods; informational only.

01/01/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER E2
04/27/10   Per LA WF Claim Check & Clear Claim Connection Orientation Presentation:
           Site Specific Modifier accepted by LA WF, must be in 1st position

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/01/10   On list of Nationally Accepted Medicare Mods; informational only.

01/01/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER E3
04/27/10   Per LA WF Claim Check & Clear Claim Connection Orientation Presentation:
           Site Specific Modifier accepted by LA WF, must be in 1st position

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/01/10   On list of Nationally Accepted Medicare Mods; informational only.

01/01/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER E4
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/01/10   On list of Nationally Accepted Medicare Mods; informational only.

01/01/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER EA
01/01/10   Can be used on J0881 and J0885 only.
MODIFIER EB
01/10/10   Can be used on J0881 and J0885 only.
MODIFIER EC
01/10/10   Can be used on J0881 and J0885 only.
MODIFIER ED
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER EE
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER EP
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER EY
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER F1
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F2
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F3
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F4
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F5
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F6
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F7
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F8
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER F9
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER FA
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/01/10   On list of Nationally Accepted Medicare Mods; informational only.

01/01/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER FB
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   ASC: There are 28 devices that require modifier FB on the procedure code (not on the device
           code) for a service that requires a device:a. for which neither the ASC, nor the beneficiary, is
           liable to the manufacturer; or b. when the manufacturer gives credit for a device being replaced
           with a more costly device; or c. when the manufacturer replaces a device listed on the table of
           devices subject to warranty or recall adjustment (found on the CMS website at
           www.cms.gov/HospitalOutpatientPPS/) and d. receives the device without cost from a
           manufacturer. Report a token charge for the device (less than $1.01) or receives a credit in the
           amount that the device is being replaced would otherwise cost.
MODIFIER FC
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)
MODIFIER FP
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER G7
01/10/10   LA MC: Can only be used with the following codes:
           59840, 59841, 59850, 59851, 59852, 59855, 59856,59857, 59866, 01964, 01965, 01966

07/08/07   Medicare Coverage of Abortion Services
MODIFIER G8
01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Use only on designated codes

01/10/10   Report with pricing modifier

05/01/09   On nationally accepted list of Medicare Modifiers




           EC
MODIFIER G9
01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Report with pricing modifier

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GA
03/31/10   Patient has signed an ABN for a serice that would otherwise deny as not medically necessary.
           ABN must be properly completed and signed for each service. Can bill patient for these
           services. (Excerpt: 13th Annual Compliance Seminar)

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   For frequency limited services, CMS allows provider to routinely ask patients to sign an ABN


10/29/09   Medlearn Matters - MM653

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GB
01/10/10   On list of Nationally Accepted Medicare Mods

10/29/09   Medlearn Matters - MM653

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GC
01/25/10   Service has been performed in part by a resident under the direction of a teaching physician
           (Anesthesia & Pain Coders Pink Sheet, January 2010)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Teaching physician must be physicially present [located in the same room (or partitioned or
           curtained area, if the room is subdivided to accommodate multiple patients) as tha patient and/or
           performs a face-to-face service] during the critical or key portions of the service that a resident
           performs; or Supervises primary care exception E&M services performed by a resident.


05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GD
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER GG
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   TN MC: Attach modifier to diagnostic mammogram code when interpretation of a screening
           mammogram results in the order of a diagnostic mammogram on the same day.
           Both the screening and diagnostic mammogram will be reimbursed.

05/01/09   On nationally accepted list of Medicare Modifiers

01/01/02   Became effective
MODIFIER GH
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   Only diagnostic should be reported and paid.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GK
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER GL
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER GP
01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GQ
01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Use only for federal telemedicine demonstration projects conducted in Alaska or Hawaii
MODIFIER GT
01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GV
01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers

01/01/02   Became effective
MODIFIER GW
03/31/10   If patient elects Hospice, must indicate that service was unrelated to terminal condition.
           (Excerpt: 13th Annual Compliance Seminar)

01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers

01/01/02   Became effective
MODIFIER GX
10/29/09   Medlearn Matters - MM653
MODIFIER GY
03/31/10   No requirement to submit statutorily non-covered services to Medicare. May bill these services
           directly to the patient, or submit as a courtesy to patient. No ABN is required for services that
           are statutorily excluded. Application of the GY mod assures a quicker denial from Medicare.
           (Excerpt: 13th Annual Compliance Serminar)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   TN MC: Examples of exclusions include routine physicals and related tests (except the
           Welcome to Medicare exam), hearing aids, and cosmetic surgery

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER GZ
01/25/10   Modifier GZ means you expect the service to be denied by your Medicare carrier as not
           reasonable and necessary and an ABN was not signed by the patient in advance of the service.
           The presence of the modifier alone does not automatically mean the claim will be denied
           (Anesthesia & Pain Coders Pink Sheet, January 2010)

01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER HA
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER J1
01/10/10   MDS is not participating in the CAP program
MODIFIER J2
01/10/10   MDS is not participating in the CAP program
MODIFIER J3
01/10/10   MDS is not participating in the CAP program
MODIFIER JC
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER JD
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER JW
06/01/10   CMS Transmittal 1962 - CMS Clarifies Billing Discarded Drug Amounts with Modifier JW

03/31/10   Excerpt from 13th annual compliance seminar - pain booklet: Trailblazers, use JW mod
           (redundent) on waste line

10/16/07   Modifier JW Support
MODIFIER KG
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER KK
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER KL
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER KT
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER KU
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER KX
03/31/10   The KX modifier, which is defined as ―Requirements specified in the medical policy have been
           met‖, is a multipurpose informational modifier for Part B professional claims. In addition to its
           other existing uses, the KX modifier should also be used to identify services that are gender
           specific (i.e., services that are considered female or male only) for effected beneficiaries on
           claims submitted by physicians and non-physician practitioners to Medicare carriers and MACs.
           Use of the KX modifier will alert the carrier/MAC that the physician/practitioner is performing a
           service on a patient for whom gender specific editing may apply, and that the service should be
           allowed to continue with normal processing. Payment will be made if the coverage and reporting
           criteria have been met for the service.

03/31/10   Additional Information:
           The official instruction, CR 6638, issued to your carrier, FI, and A/B MAC regarding this change
           may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1877CP.pdf on the CMS
           website.
           If you have any questions please contact your carrier, FI, or A/B MAC at their toll-free number,
           which may be found at
           http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS
           website.
           The MLN Matters article for MM6638 in its entirety is available on the CMS web site at
           http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6638.pdf. Effective Date: April 1,
           2010; Implementation Date: April 5, 2010

01/01/10   LA MC: Can be used with PT codes.

04/23/07   TN MC-Cigna: Modifier KX
MODIFIER LC
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   LA MC: Valid for CPT codes 92980, 92981, 92984, 92995 and 92996.

01/10/10   MS MC: Required for coronary procedures

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER LD
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   LA MC: Valid for CPT codes 92980, 92981, 92984, 92995 and 92996.

01/10/10   MS MC: Required for coronary procedures

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER LT
04/27/10   Per LA WF Claim Check & Clear Claim Connection Orientation Presentation:
           Site Specific Modifier accepted by LA WF, must be in 1st position

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Not to be used in lieu of mod 79

01/01/10   MS MC: Use for Cataract Surgery

01/01/09   MS BCBS: Eff 1/1/09, subject to new coding edits. Providers will receive Msg 318 on EDI Error
           Report requesting medical records. Not all claims will require documentation. Do not send
           unless request is received.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER M2
10/27/06   SE0703 - Assignment of dedicated MSP Modifier
MODIFIER MP
01/17/11   USER DEFINED:
           Used to flag multiple procedures that should use half the assigned RVU value

01/17/11   Each of the following F10 commands will start a special Charge Application Report that removes
           RVU‘s associated with charges that have a specific Modifier. When choosing to use any of
           these F10 commands, simply hit the F10 key, type in the command, and then follow the
           standard Charge Application Report wizard. Below is a description of each F10 command and
           what it eliminates.

           DZ167M will filter and show only those charges that do not have a Modifier = MP.

           DZ167MP will filter and show only those charges that have a Modifier = MP, and it will also half‘s
           the RVU calculation.

           DZ167M51 will remove all RVU‘s associated with charges that have a Modifier = 51.




                                                         C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsMP
C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsMP
MODIFIER MS
01/01/10   LA BC: Pays rental amount once every six months after purchase price reached for applicable
           codes.
MODIFIER NU
01/01/10   LA BC: Payment based on purchase allowable charge.
MODIFIER P1
01/26/10   CPT 2010, Appendix A

01/26/10   Anesthesia physical status modifiers (CPT book)
MODIFIER P2
01/26/10   CPT 2010, Appendix A

01/26/10   Anesthesia physical status modifiers (CPT book)
MODIFIER P3
01/26/10   CPT 2010, Appendix A

01/26/10   Anesthesia physical status modifiers (CPT book)

01/01/10   LA BC: For anesthesia, pay 1 additional unit

06/16/11   Humana does not pay for Part C.
MODIFIER P4
01/26/10   CPT 2010, Appendix A

01/26/10   Anesthesia physical status modifiers (CPT book)

01/01/10   LA BC: For anesthesia, pays 2 additional units

06/16/11   Humana does not pay for Part C.
MODIFIER P5
01/26/10   CPT 2010, Appendix A

01/26/10   Anesthesia physical status modifiers (CPT book)

01/01/10   LA BC: For anesthesia, pays an additional 3 units

06/16/11   Humana does not pay for Part C.
MODIFIER P6
01/26/10   CPT 2010, Appendix A

01/26/10   Anesthesia physical status modifiers (CPT book)
MODIFIER PA
01/26/10   Added 2010 (Medicare HCPCS 2010 Additions, December 2009)

12/04/09   Medlearn Matters - MM6718

12/01/09   Medicare Part B News - Modifiers - Requirements to Prevent the Misuse fo Modifiers PA, PB,
           and PC on Incoming Claims

10/05/09   Part B News Article - 3 Modifiers you must use for 'never event' surgeries

09/15/09   Medlearn Matters - MM6405
MODIFIER PB
01/26/10   Added 2010 (Medicare HCPCS 2010 Additions, December 2009)

12/04/09   Medlearn Matters - MM6718

12/01/09   Medicare Part B News - Modifiers - Requirements to Prevent the Misuse fo Modifiers PA, PB,
           and PC on Incoming Claims

10/05/09   Part B News Article - 3 Modifiers you must use for 'never event' surgeries

09/15/09   Medlearn Matters - MM6405
MODIFIER PC
01/26/10   Added 2010 (Medicare HCPCS 2010 Additions, December 2009)

12/12/09   One of three modifiers for 'never events', PC does not stand for 'Professional Component',
           indicates 'wrong surgery on a patient' and will trigger an automatic denial (Part B News,
           December 14, 2009, Vol. 23, No. 47)

12/04/09   Medlearn Matters - MM6718

12/01/09   Medicare Part B News - Modifiers - Requirements to Prevent the Misuse fo Modifiers PA, PB,
           and PC on Incoming Claims

10/05/09   Part B News Article - 3 Modifiers you must use for 'never event' surgeries

09/15/09   Medlearn Matters - MM6405
MODIFIER PI
01/22/10   MM6753 - Revised 010710 PET FDG for Cervical Cancer.pdf

10/16/09   Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial
           treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous
           based on other diagnostic testing. Short descriptor: PET tumor init tx strat (CR6632)


10/16/09   Medlearn Matters MM6632
MODIFIER PS
01/26/10   Added 2010 (Medicare HCPCS 2010 Additions, December 2009)

10/16/09   Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the
           subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician
           determines that the PET study is needed to inform subsequent anti-tumor strategy. Short
           descriptor: PET tumor subsq tx strategy (CR6632)

10/16/09   Medlearn Matters MM6632
MODIFIER PT
01/25/11   Per Part B Insider, Vol. 12, No. 3 :
           Modifier PT: Use This When Colorectal Screening Becomes Diagnostic
           New modifier became effective Jan. 1—here‘s how you‘ll report it.
           The question of how to code a screening colonoscopy that becomes diagnostic during the
           course of the procedure — and whether the patient‘s deductible applies — has long puzzled
           gastroenterological practices, but a new Medicare modifier solves that problem. Effective Jan. 1,
           Medicare carriers accept new modifier PT (CRC screening test converted to diagnostic test or
           other procedure) to represent this scenario. ―This tells the MAC contractor that the service
           started as a screening procedure (e.g. G0105, G0121) but an abnormality was found and the
           procedure became diagnostic or therapeutic,‖ Joel V. Brill, MD, AGAF, CHCQM tells Part B
           Insider. When appended to your procedure code, ―the modifier will indicate to Medicare to waive
           the deductible for a diagnostic procedure,‖ says Christine Ross, CPC with Digestive Healthcare
           Center in Hillsborough, N.J.
           Why the change? Practices needed a way to tell MACs that their procedures started out as
           screening services but changed to diagnostic but didn‘t want patients subjected to deductibles
           for these services. ―The Affordable Care Act waives the Part B deductible for colorectal cancer
           screening tests that become diagnostic,‖ CMS noted in MLN Matters article MM7012, which
           announced the new modifier PT (www.cms.gov/MLNMattersArticles/downloads/MM7012.pdf).
           Avoid Reporting G Code With Modifier PT
           Once the physician indicates that the screening procedure has turned diagnostic, you‘ll report
           only the diagnostic colonoscopy code, and not the screening code (G0104-G0106, G0120-
           G0121). Not only is this correct coding, but it‘s also the only way you can use modifier PT.


           The MLN Matters article notes that modifier PT should only be appended to a CPT code in the
           surgical range of 10000 to 69999. Therefore, you should not append modifier PT to a G code,
           says Brill, who represents the American Gastroenterological Association on the CPT Editorial
           Panel. For example: During a screening colonoscopy for an average-risk Medicare patient, the
           physician discovers several polyps. He removes the polyps (which are later determined to be
           benign) during the same procedure using a snare technique.
           In this case, you should report the colonoscopy with polyp removal via snare technique (such as
           45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or
           other lesion[s], by snare technique) with modifier PT appended to 45385.

           Don‘t Ditch ‗V‘ Codes
           Because your colonoscopy started out as a screening procedure, your diagnosis code should
           reflect both the screening nature of the visit and the actual condition that the physician treated.
           CMS tackled this topic in MLN Matters article SE0706, with the instruction, ―CMS advises that,
           whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a
           screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be
           indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the
           screening examination… Indicate the secondary diagnosis using the ICD-9-CM code for the
           abnormal finding (polyp, etc.).‖ This article can be accessed at
           www.cms.gov/MLNMattersArticles/downloads/SE0746.pdf. Therefore, in the example described
           above, the claim would appear with V76.51 (Special screening for malignant neoplasms, colon)
           as the primary diagnosis. You should then append the appropriate diagnostic modifier to your
           claim. For example, if the surgeon removes a benign polyp from the colon, you‘ll report 211.3
           (Benign neoplasm of colon), says Cheryl H. Ray, CCS, CPMA,
           CGCS, with Atlantic Gastroenterology, PA in Greenville, N.C.


12/10/10   Medlearn Matters 7012



                                                          C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsPT
12/10/10   The Affordable Care Act waives the Part B deductible for colorectal cancer screening tests that
           become diagnostic. The Medicare policy is that the deductible is waived for all surgical
           procedures (Current Procedural Terminology (CPT) code range of 10000 to 69999) furnished on
           the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium
           enema that were initiated as colorectal cancer screening services. Modifier ―PT‖ has been
           created effective January 1, 2011 and providers and practitioners should append the modifier
           ―PT‖ to a least one CPT code in the surgical range of 10000 to 69999 on a claim for services
           furnished in this scenario.

12/10/10   Effective January 1, 2011




                                                        C:\Docstoc\Working\pdf\8c1514a3-bf9c-483c-8ed6-ecb2d26ff003.xlsPT
MODIFIER Q0
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/01/10   Use to enter implantable cardioverter defibrillator claims in National Cardiovascular Data
           Registry.

05/01/09   On nationally accepted list of Medicare Modifiers

01/18/08   Medlearn Matters - MM5805
MODIFIER Q1
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

05/01/09   On nationally accepted list of Medicare Modifiers

01/18/08   Medlearn Matters - MM5805
MODIFIER Q4
05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER Q5
01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Should be submitted with the GV mod.

01/01/10   Claim should be billed under the attending physician's provider number, not the substituting
           physician's

01/01/10   Substitute physician is not paid by the regular physician or practice, unlike Q6 (locum tenens)
           where substitute physician is paid a per diem rate by regular physician or practice.


01/01/10   Substitute physician does not provide services over a continuous period of more than 60 days.


01/01/10   LA WF: The regular physician submits the claim and receives payment for the substitute. The
           record must identify each service provided by the substitute. Pays at 100% of the fee on file.
           NOTE: Physicians in a partnership or practicing independently who provide "on call" services for
           each other so that each can have some time away from work cannot be said to have these
           arrangements and should not use Q5 and Q6 mods. This includes OBs who are on call for one
           another and may deliver a baby of another physician's patient.

01/01/10   Substitute physician is in practice for themselves or works as part of another practice

05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Should be submitted with the GV modifier
           Claim should be billed under the attending physicians provider number, not the substituting
           physicians

01/29/08   Modifier Q5 support

01/01/02   Became effective
MODIFIER Q6
01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Regular physician or practice pays substitute a per diem rate, unlike Q5 (Reciprocal Billing)
           where substitute physician is not paid.

01/01/10   Replacement physician fills in for period not to exceed 60 continuous days.

01/01/10   Locum tenens physician is not in practice for themselves or part of another practice.

01/01/10   LA WF: The regular physician submits claims and receives payment for the substitute. The
           record must identify each service provided by the substitute. Pays at 100% of the fee on file.
           NOTE: Physicians in a partnership or practicing independently who provide "on call" services for
           each other so that each can have some time away from work cannot be said to have these
           arrangements and should not use Q5 and Q6 mods. This includes OBs who are on call for one
           another and may deliver a baby of another physician's patient.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER Q9
01/01/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER QA
01/10/10   LA MC: Must include Investigational Device Exemption (IDE) number from the manufacturer on
           the claim.

05/01/09   On nationally accepted list of Medicare Modifiers

01/18/08   Medlearn Matters - MM5805
MODIFIER QB
01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   Used only for professional services rendered by a physician.

02/01/00   Modifier QB - Medicare HPSA payments
MODIFIER QK
01/25/10   Bill the QK modifier on the anesthesiologist's claim when medically directing two to four CRNA's,
           for only one CRNA see modifier QY (Anesthesia & Pain Coders Pink Sheet, January 2010)


01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Needs a partner mod (QX)

01/01/10   Limits payment to 50%

01/01/10   LA BC: Pays at 60%

01/01/10   CIGNA: Pays at 50% of fee schedule or U&C/max reimbursable rate

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER QP
01/01/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER QR
01/01/10   On list of Nationally Accepted Medicare Mods

mm/dd/yy Medlearn Matters - MM5805
MODIFIER QS
01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   In maternity cases, can be used by Anesthesiologist or CRNA

01/01/10   Informational, use with pricing modifier

05/01/09   On nationally accepted list of Medicare Modifiers




           EC
MODIFIER QU
01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Used only for professional services rendered by a physician.

01/01/10   Effective for dates of service through Dec. 31, 2005.

02/01/00   Modifier QU support - HPSA payments
MODIFIER QV
01/18/08   Medlearn Matters - MM5805
MODIFIER QW
01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Use mod on CLIA waived status labs

01/01/10   LA WF: Pays fee on file (use of the QW does not increase or decrease reimbursement)

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER QX
01/25/10   Use modifier QX on CRNA's claim when medically directed or supervised by an anesthesiologist
           (Anesthesia & Pain Coders Pink Sheet, January 2010)

01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Needs a partner mod (QY)

01/01/10   Limits payment to 50%

11/13/09   Once a case begins, it remains in that category of medical direction or medical supervision
           despite changes in staffing. Therefore, although the anesthesiologist performed part of the
           procedure alone and part with the help of a CRNA, code based on the starting status. Bill
           anesthesiologists work with modifier QY adn the CRNAs service with modifier QX. (Conquer
           CRNA Coding wtih Modifier Know How article)

01/01/09   LA BC: Pays at 40%

01/01/09   CIGNA: Pays at 50% of fee schedule or U&C/max reimbursable rate

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER QY
01/25/10   Bill the QY modifier on the anesthesiologist's claim when medically directing only one CRNA, for
           more than one CRNA see modifier QK (Anesthesia & Pain Coders Pink Sheet, January 2010)


01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Needs a partner mod (QX)

01/01/10   Limits payment to 50%

11/13/09   Once a case begins, it remains in that category of medical direction or medical supervision
           despite changes in staffing. Therefore, although the anesthesiologist performed part of the
           procedure alone and part with the help of a CRNA, code based on the starting status. Bill
           anesthesiologists work with modifier QY adn the CRNAs service with modifier QX. (Conquer
           CRNA Coding wtih Modifier Know How article)

01/01/09   LA BC: Pays at 60%

01/01/09   CIGNA: Pays at 50% of fee schedule or U&C/max reimbursable rate

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER QZ
01/25/10   Use the QZ modifier when the nurse anesthetist provides non-medically directed anesthesia
           without the supervision of the anesthesiologist (Anesthesia & Pain Coders Pink Sheet, January
           2010)

01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Stand alone mod

01/01/10   Informational only

01/01/10   LA BC: Pays at 100%

01/01/09   CIGNA: Pays at 100% of fee schedule or U&C/max reimbursable rate

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER RC
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/10/10   On list of Nationally Accepted Medicare Mods

01/10/10   LA MC: Valid for CPT codes 92980, 92981, 92984, 92995 and 92996.

01/10/10   MS MC: Required for coronary procedures

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER RR
01/01/10   LA BC: Payment based on rental allowable charge up to purcahse allowable charge.
MODIFIER RT
04/27/10   Per LA WF Claim Check & Clear Claim Connection Orientation Presentation:
           Site Specific Modifier accepted by LA WF, must be in 1st position

01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/01/10   On list of Nationally Accepted Medicare Mods

01/01/10   Not to be used in lieu of mod 79

01/01/10   MS MC: Use for cataract surgery

01/01/09   MS BCBS: Eff 1/1/09, subject to new coding edits. Providers will receive Msg 318 on EDI Error
           Report requesting medical records. Not all claims will require documentation. Do not send
           unless request is received.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER SA
05/01/09   COVENTRY: Accepted eff 5/1/09. Reim: 85%

01/01/09   LA BC: Pays at 85%. Per Candy Williard's internal documentation, SA can be used with
           procedure codes. It is not limited to E&M since the NPP bills under the physician's provider #.


01/01/09   CIGNA: Pays at 85% of fee schedule
MODIFIER SC
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER SG
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER SL
01/01/09   CIGNA: Pays 0. NOTE: If vaccine was state supplied at no cost to the health care professional,
           append modifier SL to the appropriate CPT vaccine code and bill $0.00. Code separately for
           vaccine administration (90465-90474). Do not append modifier SL to vaccine administration
           code.
MODIFIER ST
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER T1
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T2
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T3
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T4
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T5
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T6
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T7
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T8
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER T9
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods; informational only.

01/10/10   Use of an additional modifier may be required for claim payment.

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER TA
01/26/10   Modifier approved for Hospital Outpatient use (CPT book)

01/26/10   How to Bill Multiple Services of the Same Code (LA Medicare Medguide, Modifiers)

01/10/10   On list of Nationally Accepted Medicare Mods

05/01/09   On nationally accepted list of Medicare Modifiers
MODIFIER TC
01/01/10   On list of Nationally Accepted Medicare Mods

01/10/10   LA WF: Not accepted on straight WF claims. WF will not pay Professional component and full
           service on a charge.

05/01/09   On nationally accepted list of Medicare Modifiers

01/01/09   LA BC: Pays technical component of the allowable charge.
MODIFIER TD
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER TG
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER TH
05/20/10   MS Medicaid Modifier TH Billing Policy

01/10/10   LA WF: Pays normal fee for prenatal services (exempts the recipient from the 12 visit limit)

12/10/07   LA Medicaid OB Billing Policy
MODIFIER TS
05/01/09   On nationally accepted list of Medicare Modifiers

05/01/09   Diabetes screening test performed on individual diagnosed with pre diabetes

04/01/05   Became effective
MODIFIER TV
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER UC
01/10/10   LA WF: Does not require precert.
MODIFIER Y6
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER Y7
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER Y8
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)
MODIFIER Y9
mm/dd/yy information (newest on top)

mm/dd/yy information (newest on top)

				
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posted:7/22/2011
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