by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
November 8th, 2013
Modifiers are used to help describe the
There are two types of modifiers:
- Informational modifiers that do not impact reimbursement
- Pricing or Payment modifiers that always impact reimbursement
Claims processing requires the pricing modifier in the first position to be processed correctly.
There are two levels of modifiers used to alter a procedure:
- Level I Modifiers – CPT Modifiers are two digits and updated by the AMA (American Medical Association)
- Level II Modifiers – HCPCS Modifiers are alpha Numeric characters and are updated by CMS.
Modifiers are used to help describe the
- The procedure was more complicated than anticipated
- Another procedure was required during the same procedure
- The same diagnostic test had to
be re-ran on the same day - The X-Ray was done in one facility and the results were read in a different facility
Consider this example, while doing surgery for a wrist repair 25607, during the same procedure a carpal tunnel release 64721 is done, you would append modifier 51 to show the secondary procedure was performed. Payers have what is called reimbursement edits for reporting code combinations. If using two codes are stand-alone codes they may be subject to multiple procedure payment
Using the appropriate modifiers can substantially impact reimbursement. If you do not report a modifier and the procedure allows a modifier you will not be paid for the procedure.
There are industry standards related to the use of modifiers and reimbursement. While some modifiers change the payment rates some are for informational use only or
Increased Procedural services |
Maximum of 110% of Fee Schedule Allowance/Contracted Rate with supporting documentation |
|
Bilateral Procedure |
150% of Fee Schedule Allowance/Contracted Rate Submit one line with one unit |
|
Multiple Procedures |
50% of Fee Schedule Allowances/Contracted Rate for each additional procedure unless |
|
Follow up care only |
20% of Fee Schedule Allowance/Contracted Rate |
|
Separate encounter, distinct service |
Informational /impacts bundling |
Pricing Modifiers must always be in the first position for correct reimbursement and claim processing. Use the KD modifier in the first position if there are multiple modifiers used for pricing or payment.
Below is a list of payment modifiers.
Below are links to WPS Medicare with some great information on Modifiers
Modifier |
Modifier Definition |
AA |
Anesthesia service personally performed by anesthesiologist (Do not file on same claim line with AD, QY, QK, QX, or QZ) |
AD |
Medical supervision by a physician; more than four concurrent anesthesia procedures (Do not file on the same claim line as AA, QY, QK, QX, or QZ) |
AS* |
Assistant at surgery services provided by a Physician Assistant (PA) or Nurse Practitioner (NP) |
KD** |
Drug administered through a durable medical equipment (DME) infusion pump |
QK |
Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals (Do not file on the same claim line with AA, AD, QY, QX, or QZ) |
QW |
CLIA waived tests |
QX |
Certified Registered Nurse Anesthetist (CRNA) service: with medical direction by a physician (Do not file on the same claim line as AA, AD, QY, QK, or QZ) |
QY |
Medical direction of one CRNA by an anesthesiologist (Do not file on the same claim line with AA, AD, QK, QX, or QZ) |
QZ |
CRNA service: without medical direction by a physician |
TC |
Technical component |
26 |
Professional component |
50* |
Bilateral Procedure performed at the same session on an anatomical site |
53 |
Discontinued procedure (only when appended to procedure codes 45378, G0105, G0121) |
54* |
The surgeon is billing the surgical care only |
55* |
Indicate a physician, other than the surgeon, is billing for part of the outpatient postoperative care or used by the surgeon when providing only a portion of the post-discharge post-operative care |
62* |
Two surgeons (each in a different specialty) are required to perform a specific procedure |
66* |
Team surgeons |
73* |
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) procedure prior to the administration of anesthesia |
78* |
Return to an operating room for a related procedure during the postoperative period |
80* |
Assistant at surgery service is provided by a medical doctor (MD) |
81* |
To identify minimum surgical assistant services, and is only submitted with surgery codes |
82* |
Assistant at surgery service provided by a MD when there is no qualified resident available |
Informational Only Modifier Fact Sheet
References: