Managed Care - INFO
We are the largest on-line , managed care and insurance information web site in the world !
-21 Prolonged Evaluation and Management Services: When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of evaluation and management service within a given category, it may be identified by adding modifier ü21’ to the evaluation and management code number. A report may also be appropriate.
-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier ü22’ to the usual procedure number. A report may also be appropriate.
-23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier ü23’ to the procedure code of the basic service.
-24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier ü24’ to the appropriate level of E/M service.
-25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. 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 modifier ü25’ to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier ü57.’
-26 Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding modifier ü26’ to the usual procedure number.
-27 Multiple Outpatient Hospital E/M Encounters on the Same Date: For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier ü27’ to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by a physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient settings (eg, hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.
-32 Mandated Services: Services related to mandated consultation and/or related services (eg, PRO, third party payer, governmental, legislative, or regulatory requirement) may be identified by adding modifier ü32’ to the basic procedure.
-47 Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding modifier ü47’ to the basic service. (This does not include local anesthesia.) Note: Modifier ü47’ would not be used as a modifier for the anesthesia procedures 00100<\!->01999.
-50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier ü50’ to the appropriate five digit code.
-51 Multiple Procedures: When multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier ü51’ to the additional procedure or service code(s). Note: This modifier should not be appended to designated “add-on” codes.
-52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier ü52’, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers ü73’ and ü74’ (see modifiers approved for ASC hospital outpatient use).
-53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier ü53’ to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers ü73’ and ü74’ (see modifiers approved for ASC hospital outpatient use).
-54 Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier ü54’ to the usual procedure number.
-55 Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding modifier ü55’ to the usual procedure number.
-56 Preoperative Management Only: When one physician performs the preoperative care and evaluation and another physician performs the surgical procedure, the preoperative component may be identified by adding modifier ü56’ to the usual procedure number.
-57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier ü57’ to the appropriate level of E/M service.
-58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding modifier ü58’ to the staged or related procedure. Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier ü78.’
-59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier ü59’ is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier ü59.’ Only if no more descriptive modifier is available, and the use of modifier ü59’ best explains the circumstances, should modifier ü59’ be used.
-62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier ü62’ to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If an additional procedure(s) (including an add-on procedure(s)) is performed during the same surgical session, a separate code(s) may be reported with the modifier ü62’ added. Note: If a co-surgeon acts as an assistant in the performance of an additional procedure(s) during the same surgical session, the service(s) may be reported using a separate procedure code(s) with modifier ü80’ or modifier ü82’ added, as appropriate.
-63 Procedure Performed on Infants less than 4 kg: Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients. This circumstance may be reported by adding the modifier ü63’ to the procedure number. Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20000-69999 code series. Modifier ü63’ should not be appended to any CPT codes in the E/M, Anesthesia, Radiology, Pathology/Laboratory or Medicine sections.
-66 Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating physician with the addition of modifier ü66’ to the basic procedure number used for reporting services.
-73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier ü73.’ Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier ü53.’
-74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier ü74.’ Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier ü53.’
-76 Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier ü76’ to the repeated procedure/service.
-77 Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier ü77’ to the repeated procedure/service.
-78 Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding modifier ü78’ to the related procedure. (For repeat procedures on the same day, see modifier ü76’.)
-79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier ü79.’ (For repeat procedures on the same day, see modifier ü76’.)
-80 Assistant Surgeon: Surgical assistant services may be identified by adding modifier ü80’ to the usual procedure number(s).
-81 Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier ü81’ to the usual procedure number.
-82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier ü82’ appended to the usual procedure code number(s).
-90 Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding modifier ü90’ to the usual procedure number.
-91 Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier ü91’. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when another code(s) describes a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for a laboratory test(s) performed more than once on the same day on the same patient.
-99 Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations, modifier ü99’ should be added to the basic procedure and other applicable modifiers may be listed as part of the description of the service.<\c>
-AA Anesthesia services performed personally by anesthesiologist
-AD Medical supervision by a physician: more than four concurrent anesthesia procedures
-AH Clinical psychologist
-AJ Clinical social worker
-AM Physician, team member service
-AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination
-AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
-AT Acute treatment (this modifier should be used when reporting service 98940, 98941, 98942)
-CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission
-CB Service ordered by a renal dialysis facility (RDF) physician as part of the esrd beneficiary's dialysis benefit, is not part of the composite rate, and is separately reimbursable
-CC Procedure code change (use üCC’ when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
-E1 Upper left, eyelid
-E2 Lower left, eyelid
-E3 Upper right, eyelid
-E4 Lower right, eyelid
-EJ Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab
-EM Emergency reserve supply (for ESRD benefit only)
-EP Service provided as part of medicaid early periodic screening diagnosis and treatment (EPSDT) program
-ET Emergency services
-F1 Left hand, second digit
-F2 Left hand, third digit
-F3 Left hand, fourth digit
-F4 Left hand, fifth digit
-F5 Right hand, thumb
-F6 Right hand, second digit
-F7 Right hand, third digit
-F8 Right hand, fourth digit
-F9 Right hand, fifth digit
-FA Left hand, thumb
-G1 Most recent urea reduction ratio (URR) reading of less than 60
-G2 Most recent urea reduction ration (URR) reading of 60 to 64.9
-G3 Most recent urea reduction ratio (URR) reading of 65 to 69.9
-G4 Most recent urea reduction ratio (URR) reading of 70 to 74.9
-G5 Most recent urea reduction ratio (URR) reading of 75 or greater
-G6 ESRD patient for whom less than six dialysis sessions have been provided in a month
-G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening
-G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
-G9 Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition
-GA Waiver of liability statement on file
-GB Claim being resubmitted for payment because it is no longer covered under a global payment demonstration
-GC This service has been performed in part by a resident under the direction of a teaching physician
-GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception
-GF Non-physician (e.g. nurse practitioner (NP), certified registered nurse anaesthetist (CRNA), certified registered nurse (CRN), clinical nurse specialist (CNS), physician assistant (PA)) services in a critical access hospital
-GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
-GH Diagnostic mammogram converted from screening mammogram on same day
-GJ “OPT OUT” physician or practitioner emergency or urgent service
-GK Actual item/service ordered byphysician, item associated with GA or GZ modifier
-GL Medically unnecessary upgrade provided instead of standard item, no charge, no advance beneficiary notice (ABN)
-GM Multiple patients on one ambulance trip
-GN Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care
-GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care
-GP Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care
-GQ Via asynchronous telecommunications system
-GT Via interactive audio and video telecommunication systems
-GV Attending physician not employed or paid under arrangement by the patient’s hospice provider
-GW Service not related to the hospice patient’s terminal condition
-GY Item or service statutorily excluded or does not meet the definition of any medicare benefit
-GZ Item or service expected to be denied as not reasonable and necessary
-H9 Court-ordered
-HA Child/adolescent program
-HB Adult program, non geriatric
-HC Adult program, geriatric
-HD Pregnant/parenting women's program
-HE Mental health program
-HF Substance abuse program
-HG Opioid addiction treatment program
-HH Integrated mental health/substance abuse program
-HI Integrated mental health and mental retardation/developmental disabilities program
-HJ Employee assistance program
-HK Specialized mental health programs for high-risk populations
-HL Intern
-HM Less than bachelor degree level
-HN Bachelors degree level
-HO Masters degree level
-HP Doctoral level
-HQ Group setting
-HR Family/couple with client present
-HS Family/couple without client present
-HT Multi-disciplinary team
-HU Funded by child welfare agency
-HV Funded state addictions agency
-HW Funded by state mental health agency
-HX Funded by county/local agency
-HY Funded by juvenile justice agency
-HZ Funded by criminal justice agency
-KB Beneficiary requested upgrade for ABN, more than four modifiers identified on claim
-KX Specific required documentation on file
-KZ New coverage not implemented by managed care
-LC Left circumflex coronary artery (Hospitals use with codes 92980-92984, 92995, 92996)
-LD Left anterior descending coronary artery (Hospitals use with codes 92980-92984, 92995, 92996)
-LS FDA-monitored intraocular lens implant
-LT Left side (used to identify procedures performed on the left side of the body)
-P1 A normal healthy patient
-P2 A patient with mild systemic disease
-P3 A patient with severe systemic disease
-P4 A patient with severe systemic disease that is a constant threat to life
-P5 A moribund patient who is not expected to survive without the operation
-P6 A declared brain-dead patient whose organs are being removed for donor purposes<@$>
-PL Progressive addition lenses
-Q3 Live kidney donor: services associated with postoperative medical complications directly related to the donation
-Q4 Service for ordering/referring physician qualifies as a service exemption
-Q5 Service furnished by a substitute physician under a reciprocal billing arrangement
-Q6 Service furnished by a locum tenens physician
-QB Physician providing service in a rural HPSA
-QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
-QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
-QL Patient pronounced dead after ambulance called
-QM Ambulance service provided under arrangement by a provider of services
-QN Ambulance service furnished directly by a provider of services
-QP 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
-QQ Claim submitted with a written statement of intent
-QR Repeat laboratory test performed on the same day
-QS Monitored anesthesia care service
-QV Item or service provided as routine care in a Medicare qualifying clinical trial
-QW CLIA waived test
-QX CRNA service: with medical direction by a physician
-QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
-QZ CRNA service: without medical direction by a physician
-RC Right coronary artery (Hospitals use with codes 92980-92984, 92995, 92996)
-RT Right side (used to identify procedures performed on the right side of the body)
-SA Nurse practitioner rendering service in collaboration with a physician
-SB Nurse Midwife
-SC Medically necessary service or supply
-SD Services provided by registered nurse with specialized, highly technical home infusion training
-SE State and/or federally funded programs/services
-SG Ambulatory surgical center (ASC) facility service
-SH Second concurrently administered infusion therapy
-SJ Third or more concurrently administered infusion therapy
-SK Member of high risk population (use only with codes for immunization)
-SL State supplied vaccine
-SM Second surgical opinion
-SN Third surgical opinion
-SQ Item ordered by home health
-ST Related to trauma or injury
-SU Procedure performed in physician's office (to denote use of facility and equipment)
-T1 Left foot, second digit
-T2 Left foot, third digit
-T3 Left foot, fourth digit
-T4 Left foot, fifth digit
-T5 Right foot, great toe
-T6 Right foot, second digit
-T7 Right foot, third digit
-T8 Right foot, fourth digit
-T9 Right foot, fifth digit
-TA Left foot, great toe
-TC Technical component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier üTC’ to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.
-TD RN
-TE LPN/LVN
-TF Intermediate level of care
-TG Complex/high level of care
-TH Obstetrical treatment/services, prenatal or postpartum
-TJ Program group, child and/or adolescent
-TL Early intervention/individualized family service plan (IFSP)
-TM Individualized education program (IEP)
-TN Rural/outside providers' customary service area
-TP Medical transport, unloaded vehicle
-TQ Basic life support transport by a volunteer ambulance provider
-TS Follow-up service
-TT Individualized service provided to more than one patient in same setting
-TU Special payment rate, overtime
-TV Special payment rates, holidays/weekends
-U1 Medicaid level of care 1, as defined by each state
-U2 Medicaid level of care 2, as defined by each state
-U3 Medicaid level of care 3, as defined by each state
-U4 Medicaid level of care 4, as defined by each state
-U5 Medicaid level of care 5, as defined by each state
-U6 Medicaid level of care 6, as defined by each state
-U7 Medicaid level of care 7, as defined by each state
-U8 Medicaid level of care 8, as defined by each state
-U9 Medicaid level of care 9, as defined by each state
-UA Medicaid level of care 10, as defined by each state
-UB Medicaid level of care 11, as defined by each state
-UC Medicaid level of care 12, as defined by each state
-UD Medicaid level of care 13, as defined by each state
-UF Services provided in the morning
-UG Services provided in the afternoon
-UH Services provided in the evening
-UJ Services provided at night
-UK Services provided on behalf of the client to someone other than the client (collateral relationship)
-UN Two patients served
-UP Three patients served
-UQ Four patients served
-UR Five patients served
-US Six or more patients served
-VP Aphakic patient
