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 applicable 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.

Note: To search for a specific modifier, enter "Mod" and the applicable modifier (e.g. Mod KX).

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
Mod D Ambulance Diagnostic or therapeutic site other than P or H when these are used as origin codes
Mod E Ambulance Residential, domiciliary, custodial facility (other than 1819 facility)
Mod G Ambulance Hospital Based End Stage Renal Disease (ESRD) Facility
Mod H Ambulance Hospital
Mod I Ambulance Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
Mod J Ambulance Freestanding ESRD facility
Mod N Ambulance Skilled Nursing Facility
Mod P Ambulance Physician's office
Mod R Ambulance Residence
Mod S Ambulance Scene of accident or acute event
Mod X Ambulance 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
Mod QM Ambulance Ambulance service provided under arrangement by a provider of services
Mod QN Ambulance 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

Non-covered Charges Brief Description
Mod GY Ambulance 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.
Mod QL Ambulance Patient pronounced dead after ambulance called. Mileage lines submitted as non-covered and will be denied as provider liable.
Mod TQ Ambulance 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
Mod LT Anatomic body Left side of body Mod RT Anatomic body Right side of body

Eyelid Modifiers

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

Hand Modifiers

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

Feet Modifiers

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

Coronary Artery Modifiers

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

 

Catastrophe Disaster Modifier

Modifier Description
Mod 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

 

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

Modifier Description
Mod EA End Stage Renal Disease ESRD Clinical Trial, Device and Drug Modifiers ESA, anemia, chemo-induced
Mod EB End Stage Renal Disease ESRD Clinical Trial, Device and Drug Modifiers ESA, anemia, radio-induced
Mod EC End Stage Renal Disease ESRD Clinical Trial, Device and Drug Modifiers 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
Mod FB Clinical Trial, Device and Drug Modifiers 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
Mod FC Clinical Trial, Device and Drug Modifiers 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

Modifier Description
Mod Q0 (zero) Clinical Trial, Device and Drug Modifiers 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.
Mod Q1 Clinical Trial, Device and Drug Modifiers 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
Mod JW Clinical Trial, Device and Drug Modifiers 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 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
Mod ZA Clinical Trial, Device and Drug Modifiers Biosimilar drug modifier for Sandoz. Used with HCPCS code Q5101. CR 9284
Mod ZB Clinical Trial, Device and Drug Modifiers Biosimilar drug modifier for Sandoz. Used with HCPCS code Q5102. CR 9658

Effective January 1, 2018, hospitals paid under the OPPS that are not excepted from the 340B drug payment policy for CY 2018 are required to report modifier "JG" on the same claim line as the drug HCPCS code to identify a 340B-acquired drug. Since rural SCHs, children's hospitals and PPS-exempt cancer hospitals are excepted from the 340B payment adjustment in CY 2018, these hospitals will report informational modifier "TB" for 340B-acquired drugs

Modifier Description
Mod JG Drug or biological acquired with 340B drug pricing program discount CR 10417
Mod TB Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes CR 10417

 

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 Append to indicate who actually performed anesthesia service billed.

Modifier Description
Mod 23 Critical Access Hospital CAH Unusual Anesthesia
Mod AA Critical Access Hospital CAH Anesthesia services personally performed by anesthesiologist.
Mod QK Critical Access Hospital CAH Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals. 
Mod QZ Critical Access Hospital CAH CRNA service without medical direction by a physician.
Mod QX Critical Access Hospital CAH Qualified non-physician anesthetist with medical direction by a physician.
Mod QY Critical Access Hospital CAH 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
Mod AQ Critical Access Hospital CAH Health Professional Shortage Area HPSA Physician Scarcity Area PSA Physicians providing a service in an unlisted HPSA should report this modifier.
Mod AR Critical Access Hospital CAH Health Professional Shortage Area HPSA Physician Scarcity Area PSA 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
Mod AE Critical Access Hospital CAH Practitioner Services rendered in a CAH by a nutrition professional/registered dietitian.
Mod AH Critical Access Hospital CAH Practitioner Services rendered in a CAH by a clinical psychologist.
Mod AK Critical Access Hospital CAH Practitioner For a non-participating physician service, a CAH must append this modifier on claim.
Mod GF Critical Access Hospital CAH Practitioner 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.
Mod SB Critical Access Hospital CAH Practitioner 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
Mod 1P Critical Access Hospital CAH Physician Quality Reporting System PQRS 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).
Mod 2P Critical Access Hospital CAH Physician Quality Reporting System PQRS Performance Measure Exclusion Modifier due to Patient Reasons. Includes: Patient declined; economic, social, or religious reasons; other patient reasons.
Mod 3P Critical Access Hospital CAH Physician Quality Reporting System PQRS 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.
Mod 8P Critical Access Hospital CAH Physician Quality Reporting System PQRS 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
Mod 53 Critical Access Hospital CAH Surgical 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
Mod 54 Critical Access Hospital CAH Surgical Surgical care only. Reported on surgical procedure code distinguishing practitioner providing surgical care only.
Mod 55 Critical Access Hospital CAH Surgical Postoperative management only. Reported on surgical procedure code distinguishing practitioner providing postoperative management only.
Mod 62 Critical Access Hospital CAH Surgical 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.
Mod 66 Critical Access Hospital CAH Surgical 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."
Mod 80 Critical Access Hospital CAH Surgical Assistant surgeon
Mod 81 Critical Access Hospital CAH Surgical Minimum Assistant Surgeon
Mod 82 Critical Access Hospital CAH Surgical Assistant Surgeon (when qualified resident surgeon not available)
Mod AI Critical Access Hospital CAH Surgical 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.
Mod AS Critical Access Hospital CAH Surgical Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist services for assistant-at-surgery, non-team member.
Mod GC Critical Access Hospital CAH Surgical 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

Modifier Description
Mod GQ Critical Access Hospital CAH Telehealth Via asynchronous telecommunications system
Mod GT Critical Access Hospital CAH Telehealth 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

Modifier Description
Mod ED End Stage Renal Disease ESRD 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.
Mod EE End Stage Renal Disease ESRD 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.
Mod EM End Stage Renal Disease ESRD 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.
Mod GS End Stage Renal Disease ESRD Dosage of Epoetin Alfa (EPO) or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.

Reporting the Urea Reduction Ratio (URR) for ESRD Hemodialysis Claims

All hemodialysis claims must indicate most recent URR for dialysis patient. Submit CPT 90999 and append appropriate G modifier listed below. Modifiers G1-G5 are used for patients who received seven or more dialysis treatments in a month. Modifier G6 is used for patients who have received dialysis six days or fewer in month.

Modifier Description
Mod G1 End Stage Renal Disease ESRD Urea Reduction Ratio Most recent Urea Reduction Ration (URR) reading of less than 60%
Mod G2 End Stage Renal Disease ESRD Urea Reduction Ratio Most recent URR reading of 60% to 64.9%
Mod G3 End Stage Renal Disease ESRD Urea Reduction Ratio Most recent URR reading of 65% to 69.9%
Mod G4 End Stage Renal Disease ESRD Urea Reduction Ratio Most recent URR reading of 70% to 74.9%
Mod G5 End Stage Renal Disease ESRD Urea Reduction Ratio Most recent URR reading of 75% or greater
Mod G6 End Stage Renal Disease ESRD Urea Reduction Ratio 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
Mod AY End Stage Renal Disease ESRD prospective payment system PPS 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
Mod JA End Stage Renal Disease ESRD Intravenous injection administration of ESA for ESRD
Mod JB End Stage Renal Disease ESRD Subcutaneous injection administration of ESA for ESRD
Mod JE End Stage Renal Disease ESRD 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
Mod KX End Stage Renal Disease ESRD hemodialysis 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.
Mod CG End Stage Renal Disease ESRD hemodialysis Any not medically necessary extra hemodialysis session beyond the monthly maximum. Use of modifier is attestation that additional hemodialysis sessions do not meet medical justification requirements and not paid separately.

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.

Modifier Description
Mod Q3 End Stage Renal Disease ESRD Liver Kidney Donor Surgery and Related Services

Reporting the Vascular Access for ESRD Hemodialysis Claims

ESRD claims for hemodialysis must indicate type of vascular access used. All ESRD claims must indicate if an infection was present at time of treatment. CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.9

Modifier Description
Mod V5 End Stage Renal Disease ESRD hemodialysis Vascular catheter (alone or with any other vascular access)
Mod V6 End Stage Renal Disease ESRD hemodialysis Arteriovenous graft (or other vascular access not including a vascular catheter in use with two needles)
Mod V7 End Stage Renal Disease ESRD hemodialysis 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 and CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2.

Modifier Description
Mod 24 Evaluation and Management EM 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.
Mod 25 Evaluation and Management EM 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.
Mod 27 Evaluation and Management EM 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

Modifier Description
Mod QJ Incarcerated Beneficiary 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

Modifier Description
Mod 91 Laboratory 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
Mod ET Laboratory 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.
Mod L1 Laboratory 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

Deactivated effective January 1, 2017
Mod QP Laboratory 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.
Mod QW Laboratory Clinical Laboratory Improvement Amendments (CLIA) Waived Test

 

Outpatient Rehabilitation/Therapy Modifiers

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

Modifier Description
Mod GN Outpatient Rehabilitation Therapy Services delivered under an outpatient speech language pathology plan of care
Mod GO Outpatient Rehabilitation Therapy Services delivered under an outpatient occupational therapy plan of care
Mod GP Outpatient Rehabilitation Therapy Services delivered under an outpatient physical therapy plan of care
Mod KX Outpatient Rehabilitation Therapy 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

Modifier Description
Mod CH Outpatient Rehabilitation Therapy 0% impaired, limited or restricted
Mod CI Outpatient Rehabilitation Therapy At least 1% but less than 20% impaired, limited or restricted
Mod CJ Outpatient Rehabilitation Therapy At least 20% but less than 40% impaired, limited or restricted
Mod CK Outpatient Rehabilitation Therapy At least 40% but less than 60% impaired, limited or restricted
Mod CL Outpatient Rehabilitation Therapy At least 60% but less than 80% impaired, limited or restricted
Mod CM Outpatient Rehabilitation Therapy At least 80% but less than 100% impaired, limited or restricted
Mod CN Outpatient Rehabilitation Therapy 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 and CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18.

Modifier Description
Mod GG Preventive 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.
Mod GH Preventive Diagnostic mammogram converted from screening mammogram on same day. Only a diagnostic mammogram code reported with modifier appended.
Mod PT Preventive 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.
Mod 33 Preventive
  • 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.
  • 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.

Modifier Description
Mod CG Rural Health Clinic RHC 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
Mod 22 Surgical Procedure 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
Mod 50 Surgical Procedure 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
Mod 51 Surgical Procedure 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.
Mod 52 Surgical Procedure 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
Mod 58 Surgical Procedure 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.
Mod 59 Surgical Procedure 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
Mod 73 Surgical Procedure 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
Mod 74 Surgical Procedure 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
Mod 76 Surgical Procedure Repeat procedure by same physician. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.5
Mod 77 Surgical Procedure Repeat procedure by another physician. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.5
Mod 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
Mod 79 Surgical Procedure 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
Mod BL Surgical Procedure 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
Mod CA Surgical Procedure 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
Mod CT Surgical Procedure Effective January 1, 2016, the definition of modifier – CT is "Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard." This modifier is required to be reported on claims for computed tomography (CT) scans described by applicable HCPCS codes that are furnished on non-NEMA Standard XR-29-2013-compliant equipment.

Modifier should not be used by CAHs
Mod CP Surgical Procedure Effective January 1, 2016, OPPS providers rendering stereotactic radiosurgery (SRS) planning and delivery codes not listed in MLN 9486 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.

The use of this modifier was required for CYs 2016 and 2017 and the data collection period for this modifier was set to conclude on December 31, 2017. Accordingly, for CY 2018, CMS is deleting modifier "CP" and discontinuing its required use.

Modifier should not be used by CAHs
Mod FX Surgical Procedure Effective January 1, 2017, OPPS providers must use this modifier on X-rays taken using film. MM9930
Mod FY Surgical Procedure Effective January 1, 2017, the definition of modifier FY is "X-ray taken using computed radiography technology/cassette-based imaging." This modifier is required to be reported on claims for imaging services that are x-rays taken using computed radiography technology/cassette-based imaging. Effective January 1, 2018, hospitals are required to use this modifier to report imaging services that are X-rays taken using computed radiography technology. MM10417
Mod KX Surgical Procedure 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.
Mod PA Surgical Procedure Surgical or other invasive procedure on wrong body part MM6718
Mod PB Surgical Procedure Surgical or other invasive procedure on wrong patient MM6718
Mod PC Surgical Procedure Wrong surgery or other invasive procedure on patient MM6718
Mod PI Surgical Procedure 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
Mod PN Surgical Procedure 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
Mod PS Surgical Procedure 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
Mod PO Surgical Procedure Effective January 1, 2015, the definition of modifier -PO is "Services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments." This modifier is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an off-campus provider-based department of a hospital.
Mod SC Surgical Procedure 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.
Mod XE Surgical Procedure Separate encounter. A service that is distinct because it occurred during a separate encounter. Special Edition (SE)1503
Mod XP Surgical Procedure Separate practitioner. A service that is distinct because it was performed by a different practitioner. SE1503
Mod XS Surgical Procedure Separate structure. A service that is distinct because it was performed on a separate organ/structure. SE1503
Mod XU Surgical Procedure 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

 

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

Modifier Description
Mod GA Waiver of Liability 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.
Mod GX Waiver of Liability 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.
Mod GY Waiver of Liability 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).
Mod GZ Waiver of Liability 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 Feb 19, 2018