List Of Medicare Modifiers

Modifier AI : Principal Physician of Record

Instructions

This modifier distinguishes the Principal Physician who oversees patient's care when performing evaluation and management (E/M) services and is only appended to an appropriate E/M code by that physician. It is imperative, so that other specialties may bill their claims for the same E/M code and not receive denials.

Correct Use

Append to initial/subsequent E/M codes only

        99221 – 99223 (Hospital-Initial)

        99231 – 99233 (Hospital-Subsequent)

        99291 (Critical Care)

        99304 – 99306 (SNF-Initial)

        99307 – 99310 (SNF-Subsequent)

Only principal physician of record appends to E/M code

Incorrect Use

Inappropriate for another physician to append (primary or specialty)

Claim Coding Example

Treatment Description : Principal physician of record initial inpatient visit

CPT 99222 /Modifier AI

Another specialty; initial inpatient visit, same day

99222

Modifier AY

Item or service furnished to ESRD patient - not for ESRD treatment

Instructions

If an End Stage Renal Disease (ESRD) facility needs to report a lab service (not related to ESRD treatment), they must include modifier AY to indicate item/service was not for treatment of ESRD.

Treatment : Assay of Creatinine

CPT 82565/ Modifier AY

Correct Use

ESRD facilities reporting Daptomycin revision

Separate payment available for J0878 Injection (Daptomycin, 1 mg) when furnished to an ESRD patient (not for ESRD treatment)

Incorrect Use

Inappropriate to bill J0890 with modifier AY

Consolidated billing requirement –not overridden with AY modifier

Modifiers CD, CE and CF (also known as 50/50 rule modifiers) no longer valid for use on independent laboratory claims

Correct Claim Coding

Treatment : Assay of Creatinine

CPT 82565 / Modifier AY

Modifier CR : Catastrophe/Disaster

Correct Use

This modifier must be submitted only when an item or service is impacted by an emergency or disaster.

Use for both institutional and non-institutional billing

Effective August 31, 2009: use of CR modifier is mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on the presence of a "formal waiver"

Formal Waiver: waiver of a program requirement that otherwise would apply by statute or regulation

Two types of formal waivers

Waiver of a requirement specified in Section 1135(b) of the Social Security Act. This may permit Medicare payment in a circumstance where payment would otherwise be barred.

Waiver based on a provision of the Title XVIII of the Act or its implementing regulations.

In the event of a disaster or emergency, CMS will issue specific guidance to Medicare contractors.

Incorrect Use

When there are no instructions from CMS to use the modifier

Item/service/claim was not affected by an emergency/disaster

Modifier GC

Service has been performed in part by a resident under the direction of a teaching physician

Correct Use

Append to service that has been completed by a resident in a teaching facility in part under direction and supervision of a teaching physician

Medicare does not pay for any service furnished by a medical student as defined in Internet Only Manual (IOM), Claims Processing Manual 100-04, Chapter 12, Section 100 This link takes you to an external website..

Append in second modifier field when supervising/teaching anesthesiologist is involved in two concurrent anesthesia cases with one resident (or "fellow"), he/she may bill usual base units and anesthesia time for amount of time present with resident throughout pre, intra and post anesthesia care.

Incorrect Use

Append to service when teaching physician is not involved with any part of care

Teaching Physician Documentation

Teaching physicians shall personally document that they performed the service or were physically present during key or critical portions of the service and their participation in the management of the patient. 

The physician is able to refer to the resident's documentation; however, a statement by the attending (teaching) physician is required and must include essential and independent documentation to tie into the resident's documentation. Without such documentation, no reimbursement can be made.

Examples: Acceptable

Patient became hypoxic and hypotensive. I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs and oxygen. I reviewed the resident's assessment and plan of care.

Unacceptable

I saw the patient and agree with the resident.

NOTE: In a time based setting, such as critical care, time spent teaching does not count towards the critical care time of the physician; nor does the time the resident spent with the patient. Only time spent together with the patient or the teaching physician alone can be counted towards critical care time.

Modifier GJ

"Opt out" physician or practitioner emergency or urgent services

Instructions

In an emergency or urgent care situation, a physician/practitioner who opts out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the provider may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary's behalf.

Correct Use

Example - Physician was called in to see a patient in the emergency room whom he has not seen before and no contract was signed

Claim Coding Example

CPT Code : 99282

Modifier GJ

Incorrect Use

Opt out physician to append for non-emergent services that have a private contract with patients.

Resource

Modifier GV

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

Instructions

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

Service was rendered to a patient enrolled in a Hospice.

Service was provided by a physician or non-physician practitioner identified as the patient's 'attending physician' at the time of that patient's enrollment in the Hospice program

Submit this modifier regardless of whether the services were related to the patient's terminal condition

Service was provided by a physician employed by the Hospice, you may not submit this modifier

Service was provided by a physician not employed by the Hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier

Example:  An independent attending physician or independent laboratory interprets the surgical pathology (88305) from a patient with a terminal illness related service. 

The professional component is billed to the Medicare contractor. If there is no professional component (e.g., clinical lab tests), then the Part A Hospice should only be billed.

Date of Service

Treatment : Surgical pathology (professional component)

CPT 88305 /Modifier GV

Bill to Part B: Surgical pathology (technical component)

Bill to Hospice: 88305 TC

Same rules apply for diagnostic tests

Chest x-ray (professional component)

Bill to Part B: 71010 26GV

09/25/12

Chest x-ray (technical component)

Bill to Hospice: 71010 TC

Modifier GW

Condition not related to the patient's terminal condition

Instructions

Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient's terminal condition.

All providers must submit this modifier when this condition applies.

Claim Coding Example

Patient is on hospice for congestive heart failure and goes to the office for a toe nail trim.  The procedure is unrelated. The GW modifier should be added to the CPT for the toe nail trim.

Modifier Q1

Routine clinical service provided in a clinical research study that is in an approved clinical research study

Correct Use

When a routine clinical service is performed as part of an approved clinical research study

Routine clinical services are defined as those items and services that are covered for Medicare beneficiaries outside of the clinical research study

Used for direct patient management within the study

Does not meet definition of investigational clinical services

Routine clinical services may include items or services required solely for the provision of the investigational clinical services (e.g., administration of a chemotherapeutic agent), clinically appropriate monitoring, whether or not required by investigational clinical service (e.g., blood tests to measure tumor markers) and items or services required for prevention, diagnosis, or treatment of research related adverse events (e.g., blood levels of various parameters to measure kidney function)

Incorrect Use

When service is not part of an approved clinical research study

Modifier Q0

Investigational clinical service provided in a clinical research study that is in an approved clinical research study

Correct Use

When an investigational service is performed as part of an approved clinical research study

Investigational clinical services are defined as those items and services that are being investigated as an objective within study

Investigational clinical services may include items or services that are approved, unapproved or otherwise covered (or not covered) under Medicare

Incorrect Use

When service is not part of an approved clinical research study

When service is not investigative in nature

Modifier 90, 91, 99

Modifier 90

Reference (Outside) Laboratory

Instructions

Sometimes a clinical diagnostic independent lab, place of service (POS) 81, refers a specimen to another lab for testing, where a modifier 90 is appended.

Correct Use

• Outside laboratory performs procedure, unrelated to treating/reporting physician
• In most cases, lab furnishing the service would bill the claim
• Possible for one lab to bill service performed by another lab
• Referring = referring specimen to another laboratory for testing
• Reference = lab that receives specimen from another lab and performs one or more tests on such specimen
• Must append modifier 90 to referred laboratory test code
• Item 20 mark "Yes" = outside lab
• Purchase price must be reflected under charges
• Complete item 32 with NPI, name and address where performed
• Appropriate modifier 90 claims include two different Clinical Lab Improvement Amendment (CLIA) numbers
• Reflect billing provider information
• Laboratory where services were performed (reference lab)
• Bill claims with modifier 90 and without modifier 90 separately
• If no purchased services, leave item 20 blank

Inappropriate Use

• Do not report modifier 90 with anatomic pathology and lab services
• Do not append modifier 90 for drawing fee (36415)
• Cannot be referenced out to another lab

Claim Coding Example

Treatment Description : Acute Hepatitis Panel

CPT 80074 / Modifier 90

Modifier 91

Repeat clinical diagnostic laboratory test

Instructions

This modifier is used for laboratory test(s) performed more than once on the same day on the same patient. Tests are paid under the clinical laboratory fee schedule.

Correct Use

• For necessary tests to obtain subsequent (multiple) test results
• For tests performed on the same patient on the same day
• Used with laboratory tests paid under the clinical laboratory fee schedule
• Clinical Lab Improvement Amendment (CLIA) Waived Test
• If entity holds valid waiver certificate, append modifier QW

Incorrect Use

May not be used when there are standard HCPCS codes available that describe the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc.)

May not be used when tests are rerun to confirm initial results; due to testing problems with specimens and equipment; or for any other reason when a normal, one-time, reportable result is all that is required

Does not replace modifiers such as RT, LT, 50, E1-E4, FA, F1-F9, TA, and T1-T9

Claim Example – Pathology

Modifier 99

Multiple Modifiers (same line, same code)

Instructions

When more than four modifiers are needed to describe a service on the same code, replace with modifier 99.

Correct Use

• Reflect all modifiers involved in Item 19 narrative or electronic equivalent
• Replace with modifier 99 in Item 24D
• Documentation must explain all modifiers involved
• Includes informational and pricing modifiers
• Certain modifiers may affect payment

Incorrect Use

In this situation, do not append other modifiers in Item 24D

Claim Coding Example

Patient had a Mohs removal (within 90 day global) on the left cheek and then another on the right cheek (RT) by the same provider, repeated twice (i.e., 79, 59, RT) and not enough modifier spaces.

Treatment Description : Mohs micrographic technique, including removal

CPT 17311 /Modifier 99

Modifier 50, 51, 52, 53

Modifier 50

Bilateral Procedure

Instructions

When performing a procedure on bilateral body parts, append payment modifier 50 to the appropriate code performed at the same session. The bilateral adjustment is inappropriate for (a) physiology or anatomy codes or (b) code descriptor that specifically states it is a unilateral procedure and there is an existing bilateral procedure code.

Correct Use

One line appending modifier 50 or RT and LT using one unit of service

See Bilateral Surgery Rules within Medicare Physician Fee Schedule (MPFS) Indicator Descriptions

Incorrect Use

• Inappropriate to apply an already "bilateral description" code.
• Do not append to procedures for midline organs such as the bladder, uterus, esophagus or nasal septum.
• Inappropriate to report when performed on different areas of same side of body.

Claim Coding Example

Treatment Description : Total Knee Arthroplasty

CPT 27447 /Modifier 50

Modifier 51

Multiple Procedures. When multiple procedures, other than Evaluation and Management (E/M), Physical Medicine and Rehabilitation services or provisions of supplies (e.g., vaccines) are performed at the same session by the same individual, the primary procedure or service may be reported as listed. Multiple procedure rules apply to the secondary procedure or service.

Instructions

Do not append modifier 51 to the additional procedure code. The Medicare claim processing system has a hard coded logic to append it to the correct procedure code. CPT also lists codes that are modifier 51 exempt.

Correct Use

Below are situations when multiple procedure rules apply.

• Append when same physician performs more than one surgical service at same time (Indicator 2)
• Append when technical component of multiple diagnostic procedures, Multiple Procedure Payment Reduction (MPPR) rule apply (Indicator 4)
• Append when multiple surgical procedures are done on same day but billed on two separate claims

Incorrect Use

• Do not append modifier 51 to additional procedure code
• Do not append to add-on codes (See Appendix D in the CPT manual)
• Do not append to all lines of service
• Do not append when two or more physicians each perform distinctly, different, unrelated surgeries on same day to same patient

Modifier 52

Partially Reduced or Eliminated Services

Instructions

This modifier is used to indicate partial reduction, cancellation or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. It also identifies a situation where a physician reduces or eliminates a portion of a service or procedure.

Correct Use

• Indicate statement "reduced services" in Item 19 in CMS-1500 claim form (or electronic equivalent)
• Include brief reason for reduction
• Documentation includes complete reduction reason retained in patient's record
• To determine charge amount, reduce normal fee by percentage of service not provided
• E.g., if 75% of normal service provided, reduce amount billed by 25% 
• Medicare claims processing system reimburses lower of actual charge or fee schedule allowance  

Example: Provider performs 75% of service and appends modifier 52

Medicare Physician Fee Schedule (MPFS) allowed amount* : $100

Reduced Billed Amount ($100 x 75%) : $ 75

*Medicare recognizes that many providers use one standard fee schedule for all insurance carriers. Therefore, reducing the charge amount may differ from the example.

Incorrect Use

• Do not confuse with "terminated procedure" modifier 53
• Inappropriate with E/M codes
• Inappropriate with facility billing
• Not for use in Ambulatory Surgical Center (ASC) or outpatient hospital

Special Appeal Instructions

• When submitting the Redetermination request
• Separate, concise statement explaining necessity for allowable reduction
• Submit operative report and/or chart notes

Claim Coding Example

This bilateral procedure was performed on one eye (unilateral) only. Since the code is allowed at a bilateral rate, the provider must append modifier 52 to reduce charges. In this case, it is not appropriate to use RT or LT.

Treatment Description : Fundus photography with interpretation/report; bilateral

CPT 92250 /Modifier 52

Modifier 53

Discontinued Procedure (professional services only)

Instructions

This 53 modifier allows the physician community to state the surgical procedure was discontinued due to extenuating circumstances or a threat to patient well-being.  

Correct Use

• Append in first pricing position.
• Under certain circumstances, physician may elect to terminate surgical or diagnostic procedure.
• Surgical or diagnostic procedure started and discontinued by physician.
• Prior to or after anesthesia is administered.
• Bill Medicare the percentage of service completed (see second example below).
• Medicare Claims Processing System does not automatically reduce payment.

Incorrect Use

Inappropriate with E/M or anesthesia codes

Do not use to report elective procedure cancellation, in the operating suite, prior to patient's anesthesia induction and/or surgical preparation

Inappropriate to use for Ambulatory Surgery Center (ASC) or hospital facility claims

Use facility modifiers 73 or 74

Do not confuse with "reduced procedure" modifier 52

Claim Coding Example

Treatment Description : Sigmoidoscopy; flexible; diagnostic

CPT 45330 /Modifier 53

Claim Reduction Fee Example

Provider performs 60% of service, reducing charges and appends modifier 53.

Medicare Physician Fee Schedule (MPFS) Allowed* : $200

Bill Reduced Amount ($200 x 60%) : $120

*Medicare recognizes that many providers use one standard fee schedule for all insurance carriers. Therefore, reducing the charge amount may differ from the example.

Place of Service Codes (CMS1500 box 24b) Part 3

49	Independent Clinic	A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. (effective 10/1/03)
50	Federally Qualified Health Center	A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
51	Inpatient Psychiatric Facility	A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52	Psychiatric Facility-Partial Hospitalization	A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.

Place of Service Codes (CMS1500 box 24b) Part 2

14	Group Home *	A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).
15	Mobile Unit	A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services. Special Considerations When services are furnished in a mobile unit, they are often provided to serve an entity for which another POS code exists. For example, a mobile unit may be sent to a physician's office or a skilled nursing facility. If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. However, if the mobile unit is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. Apply the nonfacility rate to payments for services designated as being furnished in POS code 15; apply the appropriate facility or nonfacility rate for the POS code designated when a code other than the mobile unit code is indicated.
16	Temporary Lodging	A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code. (effective 4/1/08)

Place of Service Codes (CMS1500 box 24b) Part 1

Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.

This code set is required for use in the implementation guide adopted as the national standard for electronic transmission of professional health care claims under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA directed the Secretary of HHS to adopt national standards for electronic transactions. These standard transactions require all health plans and providers to use standard code sets to populate data elements in each transaction. The Transaction and Code Set Rule adopted the ASC X12N-837 Health Care Claim: Professional, volumes 1 and 2, version 4010, as the standard for electronic submission of professional claims. This standard names the POS code set currently maintained by CMS as the code set to be used for describing sites of service in such claims. POS information is often needed to determine the acceptability of direct billing of Medicare, Medicaid and private insurance services provided by a given provider.

List of Place of Service Codes

List (updated March 17, 2011 )

Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity where service(s) were rendered. Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding these codes. If you would like to comment on a code(s) or description(s), please send your request to posinfo@cms.hhs.gov.

Code(s)	Place of Service Name	Place of Service Description
01	Pharmacy**	A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients. (effective 10/1/05)
02	Unassigned	N/A

CMS 1500 claim form billing instruction Part 3

HCFA BOX BLOCK 9 OTHER INSURED'S NAME

CMS 1500 claim form billing instruction Part 2

CMS 1500 claim form billing instruction Part 1

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in block 2. Otherwise, enter the word "SAME". If no Medigap benefits are assigned, leave blank. 

BLOCK 9A OTHER INSURED'S POLICY OR GROUP NUMBER
Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP. 

BLOCK 9B OTHER INSURED'S DATE OF BIRTH

Enter the Medigap enrollee's birth date (MMDDCCYY) and sex. 

BLOCK 9C EMPLOYER'S NAME OR SCHOOL NAME

CMS 1500 claim form billing instruction Part 2

CMS 1500 claim form billing instruction Part 1

BLOCK 1

Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.
Completion of this field is required for all claims.

BLOCK 1A INSURED'S I.D. NUMBER (For Program in Block 1)

Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.
Completion of this field is required for all claims.

BLOCK 2 PATIENT'S NAME

Enter the patient's last name, first name, and middle initial, if any, exactly as shown on the patient's Medicare card.
Completion of this field is required for all claims.

BLOCK 3 PATIENT'S BIRTH DATE AND SEX

CMS 1500 claim form billing instruction Part 1

CMS-1500 Complete review

CMS - 1500 form has 33 Fields and it has some uni
Claim Form
The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims.
The top right margin of the claim form should NOT contain:
any type of adhesive-backed label
printing or headings (including the Medicare carrier address)