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Modifiers

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

If appropriate, more than one modifier may be used with a single procedure code; however, modifiers are not apfplicable for every category of the CPT and HCPCS codes. Some modifiers can only be used with a particular category and some are not compatible with others.

X
 

Ambulance Modifiers

Providers must append an origin and destination modifier for each ambulance trip provided. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with exception of "X," represents an origin code or a destination code. The pair of alpha codes creates one modifier. First position alpha code equals origin; second position alpha code equals destination. While combinations of these items may duplicate other HCPCS modifiers, when billed with an ambulance transportation code, the reported modifiers can only indicate origin/destination.

Origin / Destination Brief Description
D Diagnostic or therapeutic site other than P or H when these are used as origin codes
E Residential, domiciliary, custodial facility (other than 1819 facility)
G Hospital Based End Stage Renal Disease (ESRD) Facility
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
J Freestanding ESRD facility
N Skilled Nursing Facility
P Physician's office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician's office on way to hospital (destination code only)

In addition, to describe whether service was provided under arrangement or directly by a provider, providers must report one of following modifiers with each HCPCS code.

Provided Under Arrangement or Directly Brief Description
QM Ambulance service provided under arrangement by a provider of services
QN Ambulance service furnished directly by a provider of services

Finally, when non-covered mileage occurs, providers must append appropriate non-covered modifier when patient is pronounced dead after ambulance is called or when Basic Life Support transport (BLS) is rendered by volunteer ambulance provider. CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 30-30.2.4 This link takes you to an external website.

Non-covered Charges Brief Description
GY Non-covered miles beyond closest facility are billed with HCPCS procedure code A0888 ("non-covered ambulance mileage per mile, e.g., for miles traveled beyond the closest appropriate facility"). These non-covered line items can be billed on claims also containing covered charges. May append GY modifier on line items for such non-covered mileage and liability for service will be assigned correctly to beneficiary.
QL Patient pronounced dead after ambulance called. Mileage lines submitted as non-covered and will be denied as provider liable.
TQ BLS transport by a volunteer ambulance provider. Not payable by Medicare. Lines submitted as non-covered and will be denied provider liable.

 

Anatomic Modifiers

Append when service is performed on hands, feet, eyelids, coronary artery, or left and right side of body.

Side of Body Modifiers

Modifier Brief Description Modifier Brief Description
LT Left side of body RT Right side of body

 

Eyelid Modifiers

Modifier Brief Description Modifier Brief Description
E1 Upper left, eyelid E3 Upper right, eyelid
E2 Lower left, eyelid E4 Lower right, eyelid

 

Hand Modifiers

Modifier Brief Description Modifier Brief Description
FA Left hand, thumb F5 Right hand, thumb
F1 Left hand, second digit F6 Right hand, second digit
F2 Left hand, third digit F7 Right hand, third digit
F3 Left hand, fourth digit F8 Right hand, fourth digit
F4 Left hand, fifth digit F9 Right hand, fifth digit

 

Feet Modifiers

Modifier Brief Description Modifier Brief Description
TA Left foot, great toe T5 Right foot, great toe
T1 Left foot, second digit T6 Right foot, second digit
T2 Left foot, third digit T7 Right foot, third digit
T3 Left foot, fourth digit T8 Right foot, fourth digit
T4 Left foot, fifth digit T9 Right foot, fifth digit

 

Coronary Artery Modifiers

Modifier Description
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LM Left main coronary artery
RI Ramus intermedius coronary artery
RC Right coronary artery

 

Catastrophe Disaster Modifier

Modifier Description
CR Catastrophe/disaster related. Required when item or service is impacted by emergency or disaster and Medicare payment for such item/service is conditioned on presence of "formal waiver." Medicare Learning Network (MLN) Matters 6451 – The Use of the CR Modifier and the DR Condition Code on Disaster/Emergency-Related Claims This link takes you to an external website.

 

Clinical Trial, Device and Drug Modifiers

All non-End Stage Renal Disease (ESRD) claims billed with HCPCS J0881 and J0885 must report one of Erythropoiesis Stimulating Agent (ESA) modifiers. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 80.9 This link takes you to an external website.

Modifier Description
EA ESA, anemia, chemo-induced
EB ESA, anemia, radio-induced
EC ESA, anemia, non-chemo/radio

Effective January 1, 2007, through December 31, 2013, hospitals must use the device modifiers to report when a device is furnished without cost or when partial credit for a replacement device is received. The below modifiers should not be used for services January 1, 2014, or after.

Modifier Description
FB Item provided without cost to provider, supplier or practitioner, or credit received for replacement device (e.g. covered under warranty, replaced due to defect, free samples). Do not use for services provided January 1, 2014 or after
FC Partial credit received for replacement device. Do not use for services provided January 1, 2014 or after

Providers must have an appropriate modifier to represent investigational and routine clinical services during a research study. CMS Change Request (CR)5805 – New HCPCS Modifiers when Billing for Patient Care in Clinical Research Studies This link takes you to an external website.

Modifier Description
Q0 (zero) Investigational clinical service provided in clinical research study that is in an approved clinical research study. Append this modifier on Category B Investigational Device Exemption (IDE) code along with IDE number on claim.
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study. This modifier must be billed in conjunction with diagnosis code ICD-9 code V70.7 or ICD-10 code Z00.6.

Append JW modifier to report any discarded or drug not administered to beneficiary

Modifier Description
JW Drug amount discarded/not administered to any patient. This modifier is required only on selected drugs prior to January 1, 2017.

Effective January 1, 2017, CMS Medicare Learning Network (MLN) Matters (MM)9603 This link takes you to an external website. requires the use of this modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP)).

Providers are required to use modifiers on biosimilar biological products that are paid separately.

Modifier Description
ZA Biosimilar drug modifier for Sandoz. Used with HCPCS code Q5101. CR 9284 This link will take you to an external website.
ZB Biosimilar drug modifier for Sandoz. Used with HCPCS code Q5102. CR 9658 This link will take you to an external website.

 

Critical Access Hospital (CAH) Modifiers

CAHs that have elected Method II, bill professional services on UB-04 Claim Form. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, section 250 This link takes you to an external website. Append to indicate who actually performed anesthesia service billed.

Modifier Description
23 Unusual Anesthesia
AA Anesthesia services personally performed by anesthesiologist.
QK Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals. 
QZ CRNA service without medical direction by a physician.
QX Qualified non-physician anesthetist with medical direction by a physician.
QY Medical direction of one CRNA by an anesthesiologist.

Health Professional Shortage Area (HPSA)/Physician Scarcity Area (PSA) modifiers are used for bonus payments.

Modifier Description
AQ Physicians providing a service in an unlisted HPSA should report this modifier.
AR Physicians providing services in an unlisted PSA should report this modifier.

Practitioner modifiers are used to report who actually performed the services. Method II CAH practitioners are paid at 115% of the fee schedule based on type of practitioner that rendered the services. Inappropriate reporting of practitioner modifiers may result in a Medicare overpayment.

Modifier Description
AE Services rendered in a CAH by a nutrition professional/registered dietitian.
AH Services rendered in a CAH by a clinical psychologist.
AK For a non-participating physician service, a CAH must append this modifier on claim.
GF Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN), or physician assistant (PA). If a claim is received and it has the GF modifier for CRN services, no Medicare payment should be made.
SB Services provided by a certified nurse-midwife.

Physician Quality Reporting System (PQRS) modifiers are used to indicate to special circumstances of patient's encounter with physician.

Modifier Description
1P Performance Measure Exclusion Modifier due to medical reasons. Includes: Not Indicated (absence of organ/limb, already received/performed, other); Contraindicated (patient allergic history, potential adverse drug interaction, other).
2P Performance Measure Exclusion Modifier due to Patient Reasons. Includes: Patient declined; economic, social, or religious reasons; other patient reasons.
3P Performance Measure Exclusion Modifier due to System Reasons. Includes: Resources to perform the services not available; insurance coverage/payer-related limitations; other reasons attributable to health care delivery system.
8P Performance Measure Reporting Modifier. This modifier facilitates reporting a case when patient is eligible but an action described in a measure is not performed and reason is not specified or documented.

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

Modifier Description
53 Incomplete screening colonoscopy billed on a 96X, 97X and/or 98X revenue code CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, section 60.2.A.1 This link takes you to an external website.
54 Surgical care only. Reported on surgical procedure code distinguishing practitioner providing surgical care only.
55 Postoperative management only. Reported on surgical procedure code distinguishing practitioner providing postoperative management only.
62 Two surgeons. When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding this modifier to single distinct procedure code.
66 Surgical team. This modifier should be used by each participating surgeon to report his/her services. When team surgery is medically necessary, MAC will determine appropriate allowances(s) "by report."
80 Assistant surgeon
81 Minimum Assistant Surgeon
82 Assistant Surgeon (when qualified resident surgeon not available)
AI Principal Physician of Record. CAHs report this modifier to identify primary physician overseeing patient's care from other physicians who may be furnishing specialty care.
AS Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist services for assistant-at-surgery, non-team member.
GC Indicates service has been performed in part by a resident under direction of a teaching physician.

Telehealth modifiers must be submitted with distant site telehealth services. Generally, interactive audio and video communications must be used to permit real-time communication between distant site physician/practitioner and patient. Patient must be present and participating in telehealth visit. MACs will accept and pay CPT codes G0108, G0109, G0420, G0421, 96153, 96154, 97804, 99231-99233, 99307-99310 according to appropriate physician or practitioner fee schedule amount when submitted with a GQ or GT modifier by a CAH. Providers will need to append either GQ or GT modifier based on type of telehealth communication system used. Medicare Learning Network (MLN) Matters (MM)7049 – Expansion of Medicare Telehealth Services for Calendar Year (CY) 2011 This link takes you to an external website.

Modifier Description
GQ Via asynchronous telecommunications system
GT Via interactive audio and video telecommunication systems

 

End Stage Renal Disease (ESRD) Modifiers

Claims for ESAs for ESRD patients receiving dialysis in renal dialysis facilities reporting a hematocrit level exceeding 39.0% (or hemoglobin exceeding 13.0g/dL) shall also include modifier ED or EE. For claims reporting hematocrit or hemoglobin levels exceeding monitoring threshold, the payment for the dose shall be reduced by 25% over preceding month. Providers may report that a dose reduction did occur in response to reported elevated hematocrit or hemoglobin level by adding  GS modifier on claim. If no modifier GS is reported for claims reporting a hematocrit level or hemoglobin level exceeding the monitoring threshold, CMS will reduce covered dosage reported on claim by 25%. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8 This link takes you to an external website.

Modifier Description
ED Hematocrit level has exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including current cycle.
EE Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for less than 3 consecutive billing cycles immediately prior to and including current cycle.
EM Emergency reserve supply for ESRD benefit only. In event that schedule was changed, provider should note changes in medical record and bill according to revised schedule. For patients beginning to self-administer an ESA at home receiving an extra month supply of drug, bill one-month reserve supply on one claim line and include this modifier.
GS Dosage of Epoetin Alfa (EPO) or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.

All hemodialysis claims must indicate most recent Urea Reduction Ratio (URR) for dialysis patient. Code all claims using HCPCS code 90999 along with appropriate G modifier listed below. Modifiers G1-G5 are used for patients that received seven or more dialysis treatments in a month. Modifier G6 is used for patients that have received dialysis six days or fewer in month.

Modifier Description
G1 Most recent Urea Reduction Ration (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 fewer than seven dialysis sessions have been provided in a month.

The ESRD prospective payment system (PPS) includes consolidated billing for limited Part B services included in ESRD facility bundled payment. When laboratory services and limited drugs are provided to a beneficiary but are not related to treatment for ESRD, claim lines must be submitted with AY modifier to allow for separate payment outside of ESRD PPS.

Modifier Description
AY Item or service furnished to an ESRD patient that is not for treatment of ESRD.

ESRD facilities billing for injections of ESA for ESRD beneficiaries must include modifier indicating type of administration of ESA.

Modifier Description
JA Intravenous injection administration of ESA for ESRD
JB Subcutaneous injection administration of ESA for ESRD
JE Append this modifier to all ESRD claims where drugs and biologicals are furnished to ESRD beneficiaries via dialysate solution on claims with dates of service on/after July 1, 2013

Any medically necessary extra hemodialysis sessions beyond the monthly maximum must be indicated on the claim form with the use of CPT 90999 and the KX modifier.

Modifier Description
KX Any medically necessary extra hemodialysis sessions beyond the monthly maximum. Noridian reviews the medical justification for additional treatments and is responsible for making the decision on the appropriateness of the extra treatments. The documentation in the patient's medical record must support the reason why extra hemodialysis sessions were given beyond the frequency.

For covered postoperative care/services for live kidney donor, Q3 modifier must be reported with service in order to receive 100% reimbursement. If kidney donor services are from a cadaver, they are a considered part of organ acquisition program and should be billed to Medicare Part A. See more CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, section 90 This link takes you to an external website..

Modifier Description
Q3 Liver Kidney Donor Surgery and Related Services

ESRD claims for hemodialysis must indicate type of vascular access used to deliver hemodialysis. Additionally, all ESRD claims must indicate if an infection was present at time of treatment.

Modifier Description
V5 Vascular catheter (alone or with any other vascular access)
V6 Arteriovenous graft (or other vascular access not including a vascular catheter in use with two needles)
V7 Arteriovenous fistula only (in use with two needles)

 

Evaluation and Management (E&M) Modifiers

E&M modifiers are used to note special circumstances of a patient's encounter with physician. It is only appropriate to append modifiers 24, 25 and 27 on E&M codes. Documentation in patient's medical record must support use of modifier. See more Medicare Learning Network (MLN) Matters Global Surgery Fact Sheet This link takes you to an external website. and CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2 This link takes you to an external website..

Modifier Description
24 Unrelated E&M service by same physician during a postoperative period. This modifier can be used to indicate that an E&M service or eye exam, which falls within global period of a major or minor surgery and is performed by a surgeon, is unrelated to surgery. This can only be submitted with E&M and eye exam codes. When submitted, supporting documentation of an unrelated ICD-9 or ICD-10 code and/or additional documentation may be requested to support that E&M service is unrelated to surgery. If ICD-9 or ICD-10 code for E&M service clearly supports that visit was unrelated to surgery, there is no need to submit additional documentation.
25 Significant, separately identifiable E&M service by the same physician on the same day as the procedure or other service with a 0-day or 10-day global period. The physician may need to indicate that on the day a procedure or service 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. 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. This circumstance may be reported by adding the modifier 25 to the appropriate level of E&M service.
27 Multiple Outpatient Hospital E&M Encounters on Same Day. Hospitals may append this modifier to second and subsequent E&M code when more than one E&M service is provided to indicate that E&M service is "separate and distinct E&M encounter" from service previously provided that same day in same or different hospital outpatient setting. When reporting this modifier, report with condition code G0 (zero) when multiple medical visits occur on same day in same revenue centers.

 

Incarcerated Beneficiary Modifier

The incarcerated beneficiary modifier may be used to report services for individuals who are in custody including, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. Services will need to be submitted as non-covered as services provided to beneficiaries in custody are statutorily excluded from the Medicare Program. MM6880 This link takes you to an external website.

Modifier Description
QJ Services/items provided to a prisoner or patient in state or local custody; however, the state or local government, as applicable, meets requirements in 42 CFR 411.4(B). For outpatient claims, providers shall append this modifier on all lines with a line item date of service during incarceration period. All associated charges should be billed as non-covered.

 

Laboratory Modifier

Laboratory modifiers are used when laboratory code(s) are separately identifiable and payment is not included in another service. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 16 This link takes you to an external website.

Modifier Description
91 Repeat clinical diagnostic laboratory test. CMS IOM, Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 Correct Coding Initiative, section 20.4 This link takes you to an external website.
ET Attestation that laboratory test(s) were ordered in conjunction with emergency treatment. Services rendered to Skilled Nursing Facility (SNF) and ESRD beneficiaries that include an emergency room service with revenue code 045x on a line item date of service (LIDOS) that differs from LIDOS for related laboratory test(s) hospital must include this modifier to attest that laboratory test(s) were ordered in conjunction with emergency services.
L1

Provider Attestation that the Hospital Laboratory test(s) is not packaged under Outpatient Prospective Payment System (OPPS). Do not report if the hospital only provides outpatient laboratory tests to the patient and no other hospital outpatient services on the claim. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, section 30.3 This link takes you to an external website.

Deactivated effective January 1, 2017

QP Panel test. Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes 80002-80019, G0058, G0059, and G0060. Information only. Attestinging documentation is on file.
QW Clinical Laboratory Improvement Amendments (CLIA) Waived Test

 

Outpatient Rehabilitation/Therapy Modifiers

Identifies discipline of plan of care under which service is delivered.

Modifier Description
GN Services delivered under an outpatient speech language pathology plan of care
GO Services delivered under an outpatient occupational therapy plan of care
GP Services delivered under an outpatient physical therapy plan of care
KX Used to indicate the services rendered are medically necessary

The functional reporting modifiers are used in conjunction with function related G series codes for physical therapy (PT), occupation therapy (OT), and speech language pathology (SLP) to indicate severity/complexity of beneficiary's percentage of functional impairment as determined by clinician furnishing the therapy services. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.3; Section 10.6, Letter F; Section 20; Letter B This link takes you to an external website.

Modifier Description
CH 0% impaired, limited or restricted
CI At least 1% but less than 20% impaired, limited or restricted
CJ At least 20% but less than 40% impaired, limited or restricted
CK At least 40% but less than 60% impaired, limited or restricted
CL At least 60% but less than 80% impaired, limited or restricted
CM At least 80% but less than 100% impaired, limited or restricted
CN 100% impaired, limited or restricted

 

Preventive Modifiers

Preventive modifiers are used to indicate service(s) rendered were preventive. By including one of the modifiers below to the applicable CPT codes deductible and/or coinsurance will not be applied. See more at MM 8874 – Preventive and Screening Services – Update – Intensive Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia Associated Screening Colonoscopy This link takes you to an external website. and CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18 This link takes you to an external website..

Modifier Description
GG Diagnostic mammography. Performance and payment of a screening mammography and diagnostic mammography on same patient, on the same day. Reported on diagnostic mammography code and no modifier reported on screening mammography.
GH Diagnostic mammogram converted from screening mammogram on same day. Only a diagnostic mammogram code reported with modifier appended.
PT Colorectal cancer screening test;  converted to diagnostic test or other procedure. Appended to diagnostic procedure code that is reported instead of the screening colonoscopy or screening sigmoidoscopy HCPCS code within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services furnished on the same date of service as the procedure.
33
  • Claims with dates of service on/or after January 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service (CPT 00810) in conjunction with a screening colonoscopy (HCPCS G0105 or G0121) must include modifier 33 to waive the beneficiary coinsurance and deductible. See MM 8874 This link takes you to an external website..
  • Effective January 1, 2016, append modifier 33 to Advance Care Planning (ACP) HCPCS 99497 (first 30 minutes) and/or 99498 (each additional 30 minutes) when provided on same day as Annual Wellness Visit (AWV) to waive coinsurance and deductible.

 

Rural Health Clinic (RHC)

From April 1, 2016 through September 30, 2016, all charges for a visit must be reported on service line with qualifying visit HCPCS code, minus any charges for preventive services using revenue code 052x for medical services and/or revenue code 0900 for mental health services. RHCs are allowed to report additional 052x or 0900 revenue code lines. Beginning on October 1, 2016, Medicare Administrative Contractors (MACs) will accept modifier CG on RHC claims and adjustments. Refer to MM SE 1611 This link will take you to an external website..

Modifier Description
CG Policy criteria applied effective October 1, 2016.
  • RHCs report on one revenue code 052x and/or 0900 service line, which includes all charges subject to coinsurance and deductible
  • Reported to indicate which revenue code 052x and/or 0900 service line should receive the all-inclusive rate (AIR) and subject to coinsurance and deductible.
  • Do not report on additional services furnished during visit

 

Surgical/Procedure Modifiers

Surgical or procedure modifiers are used to provide more specificity on additional services, reduction in services and repeat services occurring during an encounter or subsequent encounter. Surgical or procedure modifiers are used on diagnostic and surgical procedures.

Modifier Description
22 Increased procedural services (surgical/procedures codes only). This should only be used when documentation indicates work performed is substantially greater than typically required by technical difficulty, severity of patient's condition or increased intensity and time. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.15 This link takes you to an external website.
50 Bilateral procedure. May be used with diagnostic and radiology procedures as well as with surgical procedures. It should be used to report bilateral procedures that are performed at same operative session as a single line item. Modifiers RT and LT are not used when modifier 50 applies. A bilateral procedure is reported on one line using modifier 50. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.2 This link takes you to an external website.
51 Report for multiple procedures on same day. Do not report on E&M services. This is not required on Medicare claims as the system will apply payment reduction appropriately; however, providers are allowed to add this modifier when appropriate. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.6 This link takes you to an external website..
52 Reduced or elimination of a procedure for which anesthesia is not planned. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6 and 20.6.4 This link takes you to an external website.
58 Staged or related procedure or service during postoperative period. This modifier should be used to permit payment for a surgical procedure during postoperative period of another surgical procedure when subsequent procedure was planned prospectively at time of original procedure, a less extensive procedure fails and a more extensive procedure is required or a therapeutic surgical procedure follows a diagnostic procedure e.g., a mastectomy follows a breast biopsy. Failure to use modifier when appropriate may result in denial of subsequent surgery.
59 Distinct procedural service. Used to identify procedures or services, other than E&M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, 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 same day by same individual. It does not replace modifiers 25, 27, 50, 77, 78, RT and LT; and should only be used when there is no other modifier fitting this description. CMS IOM, Publication 100-09, Medicare Contractor Beneficiary and Provider Communication Manual, Chapter 5, Section 20.4 This link takes you to an external website.
73 Discontinued outpatient hospital prior to administration of anesthesia. Indicates procedure requiring anesthesia was terminated due to extenuating circumstances or circumstances that threatened well-being of patient after patient had been prepared for procedure (including procedural pre-medication when provided), and patient had been taken to room where procedure was to be performed, but prior to administration of anesthesia. For purposes of billing for services furnished in hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia or general anesthesia. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.4 This link takes you to an external website.
74 Discontinued outpatient hospital procedure after administration of anesthesia. Indicates a procedure requiring anesthesia was terminated after induction of anesthesia or after procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well-being of the patient. This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at physician's discretion after administration of anesthesia. For purposes of billing for services furnished in hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia and general anesthesia. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.4 This link takes you to an external website.
76 Repeat procedure by same physician. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.5 This link takes you to an external website.
77 Repeat procedure by another physician. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.5 This link takes you to an external website.
78 Return to operating room for related surgery during postop period. Use on surgical codes only to indicate that another procedure was performed during postoperative period of initial procedure, was related to first, and required use of operating room. Payment is limited to amount allotted for intraoperative services only. Failure to use this modifier when appropriate may result in denial of subsequent surgery. Medicare Learning Network (MLN) Matters Global Surgery Fact Sheet This link takes you to an external website.
79 Unrelated procedure or service by same physician during a postoperative
period. The physician may need to indicate that a procedure or service furnished during a postoperative period was unrelated to original procedure. A new postoperative period begins when unrelated procedure is billed. Medicare Learning Network (MLN) Matters Global Surgery Fact Sheet This link takes you to an external website.
BL Special acquisition of blood and blood products. Report when facility pays for actual blood or blood products, in addition to paying for processing and storage costs. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 231.2 This link takes you to an external website.
CA Procedure payable only in inpatient setting when performed emergently on an outpatient who expires prior to admission. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.7 This link takes you to an external website.
CT Effective January 1, 2016, OPPS providers must report this modifier on computed tomography (CT) services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013. Required on claims for CT scans described by HCPCS codes 70450 - 70498; 71250 - 71275; 72125 - 72133; 72191 - 72194; 73200 - 73206; 73700 - 73706; 74150 - 74178; 74261 - 74263; and 75571 - 75574. This modifier should not be reported with CT scans not listed above.

Modifier should not be used by CAHs
CP Effective January 1, 2016, OPPS providers rendering stereotactic radiosurgery (SRS) planning and delivery codes not listed in MLN 9486 This link takes you to an external website. must report the CP modifier. Do not report on TOB 13X for adjunctive or related SRS treatment but billed on a different date of service and within 30 days prior or 30 days after the date of services for either CPT code 77371 or 77372.

Modifier should not be used by CAHs
FX Effective January 1, 2017, OPPS providers must use this modifier on X-rays taken using film. MM9930 This link takes you to an external website.
KX Reported by providers billing for single or dual pacemakers as an attestation that the service documentation is on file verifying the patient has non-reversible symptomatic bradycardia. MLN 9078.
PA Surgical or other invasive procedure on wrong body part MM6718 This link takes you to an external website.
PB Surgical or other invasive procedure on wrong patient MM6718 This link takes you to an external website.
PC Wrong surgery or other invasive procedure on patient MM6718 This link takes you to an external website.
PI Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing. Providers billing an initial treatment strategy for solid tumors with HCPCS codes 78608, 78811, 78812, 78813, 78814, 78815 or 778816 must append this modifier. MM6632 This link takes you to an external website.
PN Effective January 1, 2017, non-excepted off-campus provider-based departments of a hospital are required to report this modifier on each claim line for non-excepted items and services. MM9930 This link takes you to an external website.
PS PET or PET/CT to inform subsequent treatment strategy of cancerous tumors when beneficiary's treating physician determines that PET study is needed to inform subsequent anti-tumor strategy. Providers billing a subsequent treatment strategy for solid tumors with HCPCS codes 78608, 78811, 78812, 78813, 78814, 78815 or 778816 must append this modifier. MM6632 This link takes you to an external website.
PO Effective January 1, 2015, services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments paid under the Outpatient Prospective Payment System (OPPS), must report modifier PO with every HCPCS code. This modifier should not be reported for remote locations of a hospital, satellite facilities of a hospital, for services furnished in an emergency department, or for services at a CAH. Reporting of this modifier is voluntary for 2015; reporting of this modifier is required beginning January 1, 2016. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, section 20.6.11 This link takes you to an external website.
SC Medically necessary service or supply. For medically necessary pacemaker insertion in conditions not addressed in NCD 20.8.3 or Noridian's Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Billing and Coding; Append SC modifier to pacemaker group III criteria.
XE Separate encounter. A service that is distinct because it occurred during a separate encounter. Special Edition (SE)1503 This link takes you to an external website.
XP Separate practitioner. A service that is distinct because it was performed by a different practitioner. SE1503 This link takes you to an external website.
XS Separate structure. A service that is distinct because it was performed on a separate organ/structure. SE1503 This link takes you to an external website.
XU Unusual non-overlapping service. The use of a service that is distinct because it does not overlap usual components of the main service. MLN SE1503 This link takes you to an external website.

 

Waiver of Liability Modifiers

Liability waiver modifiers will deny services as not reasonable and medically necessary. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.4 This link takes you to an external website.

Modifier Description
GA Waiver of liability statement issues, as required by payer policy. Advanced Beneficiary Notice (ABN) of liability required. Modifier is used to signify a line item is linked to the mandatory use of an ABN when charged both related to and not related to an ABN must be submitted on the claim. Line item must be submitted as covered, and Medicare will make the determination for payment.
GX Notice of liability issued, voluntary under payer policy. This modifier should be used to report when a voluntary ABN was issued for a service. Lines submitted as non-covered will be denied as beneficiary-liable.
GY Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Lines submitted as non-covered and will be Patient Responsibility (PR).
GZ Item or service expected to be denied as not reasonable and necessary. Cannot be used when ABN is given. Lines submitted as non-covered will be denied as provider-liable.

 

Resources

Last Updated Mar 27, 2017