Medical Coding Modifiers: A Guide for Accurate Medical Billing
Discover what medical coding modifiers are and their crucial role in accurate coding and billing. Learn about modifiers like 51, 52, 53, and 76, and understand when and how to use them.
Medical Coding Modifiers
A medical coding modifier is a two-character code of letters or numbers added to a CPT or HCPCS Level II code. This modifier gives extra information about the medical procedure, service, or supply involved without altering the fundamental meaning of the original code. Medical coders use modifiers to clarify the specifics of an encounter.
For example, a modifier may be applied to show that a service did not occur precisely as outlined in the CPT or HCPCS Level II code description. Still, the deviation does not warrant changing the code. Modifiers can also convey additional details not included in the code descriptor, such as the specific anatomical location where a procedure was performed. Additionally, certain payer programs may require specific modifiers when reporting codes for services related to those programs.
Proper Use of Modifiers in CPT Coding
The CPT code book provides several scenarios where a modifier may be necessary:
- When a service or procedure includes both professional and technical components.
- If more than one provider is involved in performing the service or procedure.
- When the procedure occurs in multiple locations.
- If the service or procedure is increased or reduced compared to the standard code description.
- For bilateral procedures.
- When a service or procedure is provided to a patient more than once.
Accurate use of modifiers is crucial for correct coding, as some can influence provider reimbursement. Incorrect or omitted modifiers can lead to claim denials, causing additional work, payment delays, and potential loss of reimbursement.
Understanding CPT Modifiers
The American Medical Association (AMA) maintains the copyright for CPT, and CPT modifiers are typically two-digit codes. However, for performance measures, modifiers that apply specifically to CPT Category II codes are alphanumeric, ranging from 1P to 8P.
Here are some examples of commonly used CPT modifiers:
- 25: Indicates a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified healthcare professional on the same day as a procedure or other service.
- 26: Denotes the professional component of a service.
- 59: Identifies a distinct procedural service.
HCPCS Level II Modifiers
The Centers for Medicare & Medicaid Services (CMS) manages HCPCS Level II codes and modifiers. These modifiers are alphanumeric and can include two letters.
Here are a few examples of HCPCS Level II modifiers:
- E1: Refers to the upper left eyelid.
- TC: Indicates the technical component of a service. Sometimes, a charge may be made for the technical component alone. This is identified by adding the modifier 'TC' to the usual procedure number. Technical component charges are institutional and not billed separately by physicians, but portable X-ray suppliers use this modifier to bill for technical components.
- XS: Represents a separate structure, indicating a service performed on a distinct organ or structure.
HCPCS Level II modifiers are listed in HCPCS Level II code books and available through online coding resources. Since the HCPCS Level II code set is not copyrighted, modifiers are publicly accessible on CMS’ Alpha-Numeric HCPCS site and the HCPCS Quarterly Update site.
Types of Modifiers - Pricing vs. Informational
Modifiers in medical coding are categorized not only by their code set—CPT or HCPCS Level II—but also by their function. Two key categories are pricing modifiers and informational modifiers.
Pricing Modifiers
Pricing modifiers affect the pricing of the reported code. According to Medicare's Multi-Carrier System (MCS) for claims processing, pricing modifiers must be placed in the first modifier position before any informational modifiers. On the CMS 1500 claim form, this means entering the pricing modifier directly to the right of the procedure code in field 24D. Most providers use the electronic version of this form for Medicare billing of professional services.
Claims submitted without the pricing modifier in the correct position may face processing delays. To ensure proper reporting and placement of modifiers, payers often provide guidelines. For example, the WPS Government Health Administrators (WPS GHA) site offers a Pricing Modifier Fact Sheet that details which modifiers to use and how to position them if multiple pricing modifiers are needed.
Informational Modifiers
Informational or statistical modifiers are used in medical coding but do not directly impact payment. They are placed after pricing modifiers on a claim form.
Although these modifiers are termed "informational," they can still influence reimbursement. For example, modifier 59 is commonly used to override Medicare's National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, allowing payment for both codes in an edit pair. Despite its impact on payment, modifier 59 is classified as an informational modifier rather than a payment modifier. For instance, the WPS Government Health Administrators (WPS GHA) site categorizes modifier 59 as informational.
It's important to note that the categorization of modifiers can vary between payers. Therefore, medical coders must stay updated on individual payer policies to ensure correct modifier placement and avoid claim processing issues.
NCCI Modifiers
NCCI PTP-associated modifiers are specific modifiers approved by Medicare and Medicaid to bypass NCCI Procedure-to-Procedure (PTP) edits under appropriate clinical conditions. This process, known as unbundling, allows for the separate billing of services that might otherwise be bundled together.
Modifier 59, as mentioned earlier, is one example of an NCCI PTP-associated modifier that can override such edits. The comprehensive list of these modifiers is detailed in two key resources:
- National Correct Coding Initiative Policy Manual for Medicare Services
- National Correct Coding Initiative Manual for Medicaid Services
The complete list of NCCI PTP-associated modifiers is categorized into three main groups: Anatomic Modifiers, Global Surgery Modifiers, and Other Modifiers. These categories help Medicare and Medicaid manage and apply modifiers effectively.
NCCI PTP-Associated Modifiers
Anatomic Modifiers
- E1-E4: Eyelids
- FA, F1-F9: Fingers and thumbs
- TA, T1-T9: Toes
- LT, RT: Left side and right side of the body
- LC, LD, RC, LM, RI: Coronary arteries
Global Surgery Modifiers
- 24: Unrelated postoperative evaluation and management (E/M) service
- 25: Separate E/M service on the same day as another procedure
- 57: Decision for surgery
- 58: Staged or related postoperative procedure
- 78: Unplanned return to the operating room
- 79: Unrelated postoperative procedure
Other Modifiers
- 27: Multiple same-date outpatient hospital E/M services
- 59: Distinct procedural service
- 91: Repeat laboratory tests
- XE, XP, XS, XU: Separate encounter, practitioner, structure, service
NCCI Modifier 25 - Separate E/M Service
Modifier 25 indicates a significant, separately identifiable evaluation and management (E/M) service provided by the same physician or qualified healthcare professional on the same day as another procedure or service. To qualify for separate reimbursement with modifier 25, the E/M service must meet specific criteria:
Significant, Separately Identifiable E/M Service
Determining whether an E/M service is significant and separately identifiable can be challenging. The documentation must demonstrate that the provider performed additional E/M work beyond what is generally required for the procedure or service on the same day. If you removed the documentation related to the procedure or service, the remaining documentation should still support reporting the E/M code independently.
Diagnosis Considerations
According to the Medicare and Medicaid NCCI manuals, it is acceptable for the diagnosis to be the same for both the procedure/service and the separate E/M service. However, experienced coders often find that using different ICD-10-CM codes for the procedure/service and the E/M service can expedite claim processing. This approach makes the distinct reasons for each service more apparent. Nonetheless, different diagnosis codes should only be reported if supported by documentation and applicable coding guidelines.
Same Physician or Other Qualified Healthcare Professional - Modifier 25
Medical coders should refer to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.5, to correctly interpret the "same physician" requirement for using modifier 25.
This rule stipulates that:
Physicians within the same group practice and specialty are considered a single entity for billing purposes. Suppose multiple evaluation and management (E/M) services are provided on the same day to the same patient by the same physician or by different physicians in the same specialty within the same group.
In that case, only one E/M service can be reported unless the services address unrelated issues. Instead of billing each E/M service separately, the physicians should consolidate the visits into a single level of service and submit the appropriate code for that combined level.
Same Day of the Procedure or Other Service
Determining if an evaluation and management (E/M) service occurred on the same date as another procedure or service is straightforward. Still, there are specific considerations related to Medicare's global surgery rules.
You may append modifier 25 to an E/M code if it is reported on the same day as a minor surgical procedure code, which has a global period indicator of 000 or 010 on the Medicare Physician Fee Schedule (MPFS), as outlined in Chapter I.E of the Medicare NCCI Manual. Modifier 25 can also be used with an E/M code reported on the same date as a code with a global indicator of XXX.
However, be aware that procedure codes with a global period indicator of 000 (0-day global), 010 (10-day global period), or XXX (global rules not applicable) already include pre-, intra-, and post-procedure work. Therefore, you should refrain from reporting an additional E/M code for this work, even with modifier 25.
For decisions related to performing a major surgery (with a 090-day global period), you should use modifier 57, Decision for Surgery, rather than modifier 25. The Medicare NCCI Manual indicates that the decision to perform a minor surgical procedure is included in the procedure code, so a separate E/M code should not be reported.
Scenario For Modifier 25
A physician evaluates a patient with head trauma and determines that sutures are needed. After reviewing the patient's allergy and immunization history, the physician performs the suturing procedure. In this case, the evaluation and management (E/M) service related to the decision for the procedure is not separately reportable.
However, if the physician conducts a medically necessary complete neurological examination for the head trauma patient, this additional E/M service can be reported separately. In such a situation, you would append modifier 25 to the E/M code to indicate that the E/M service was significant and separately identifiable from the procedure performed on the same day.
NCCI Modifiers 59 and X(EPSU) - Distinct Service
Modifier 59, Distinct Procedural Service, indicates that a procedure or service is separate and distinct from other services or procedures reported on the same day. This modifier signifies that the code represents a distinct procedure that warrants separate payment despite typically not being reported together.
Criteria for Using Modifier 59
To determine if modifier 59 is appropriate, the CPT® definition suggests that documentation should support one of the following conditions:
- A separate patient encounter or session
- A different procedure or surgery
- A different anatomic site or organ system
- A separate incision or excision
- A separate lesion
- A separate injury (or area of injury in the case of extensive injury)
If a more descriptive modifier is available, such as an anatomic modifier, it should be used instead of modifier 59 to better represent the distinct nature of the procedures.
Example Scenario
For instance, the third-quarter 2022 Medicare NCCI PTP edits include an edit pair for 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) and 29820 (Arthroscopy, shoulder, surgical; synovectomy, partial). This edit pair has a modifier indicator of “1,” meaning you can bypass the edit under appropriate clinical circumstances. According to the MLN Fact Sheet, “Proper Use of Modifiers 59 & -X{EPSU},” modifier 59 or -X{EPSU} should not be used if both procedures are performed on the same shoulder during the same operative session. Instead, use modifiers RT and LT if the procedures are performed on different shoulders.
X(EPSU) Modifiers
In addition to modifier 59, coders should consider using the X(EPSU) modifiers, which offer more specific alternatives for indicating distinct services. Medicare introduced these HCPCS Level II modifiers to provide greater specificity:
- XE: Separate Encounter: This modifier indicates that the service is distinct because it occurred during a separate encounter.
- XP: Separate Practitioner: This modifier signifies that the service is distinct because a different practitioner performed it.
- XS: Separate Structure: This modifier denotes that the service is distinct because it was performed on a separate organ or structure.
- XU: Unusual Non-overlapping Service: This modifier describes a distinct service that does not overlap with the leading service's usual components.
In a 2014 announcement, CMS noted that while using these modifiers can help clarify the reasons for a distinct service, the application of modifier 59 persists. The X(EPSU) modifiers offer more detailed explanations for the distinct nature of a service, which can help auditors, payers, and providers understand the context and reduce reporting errors.
Although Medicare continues to accept modifier 59, it's essential to verify with individual payers which modifiers they prefer for reporting distinct procedural services.
NCCI Medicare Global Package Modifiers
Modifiers are essential for reporting services performed during the global period of a surgical code, which includes routine services before, during, and after a procedure.
Medicare’s global surgical package covers these routine services within the surgery code fee for work done by same-specialty members of the same group. Besides modifiers 25 and 57 commonly discussed, the following NCCI Global Surgery Modifiers may also identify separately payable services during the global period.
Modifier 24 - Unrelated E/M
Modifier 24, "Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional During a Postoperative Period," is used exclusively with E/M codes to denote services unrelated to the original procedure with a global period.
This modifier is appropriate when an E/M service is performed for a condition or issue not connected to the primary surgical procedure.
For instance, if a biopsy reveals a malignant tumor and a patient returns during the biopsy’s global period for suture removal and a separate E/M visit to discuss the diagnosis and treatment options, the E/M service can be reported with modifier 24. Routine suture removal and post-biopsy care are included in the global period and are not separately reportable.
Medicare’s Global Surgery Booklet confirms that modifier 24 applies to “treatment for the underlying condition or an additional course of treatment not part of normal recovery from surgery.”
Similarly, CPT guidelines state: “Care of the condition for which the diagnostic procedure was performed or other concomitant conditions are not included and may be listed separately.”
Modifier 58 - Staged/Related Procedure
Modifier 58, "Staged or Related Procedure or Service by the Same Physician or Other Qualified Healthcare Professional During the Postoperative Period," is used to indicate that a procedure performed during the global period is either planned prospectively, more extensive than the original procedure, or for therapeutic purposes following a diagnostic procedure.
When using modifier 58, you signal that the subsequent procedure was anticipated at the time of the original surgery or is related to it. Reporting this modifier initiates a new postoperative period for the staged or related procedure.
Modifier 78 - Unplanned Return to OR
Modifier 78, "Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Healthcare Professional Following Initial Procedure for a Related Procedure During the Postoperative Period," is applied when a patient needs to return unexpectedly to the operating room for a procedure related to the initial surgery.
This modifier is often used to report complications that necessitate additional surgery. Medicare defines an operating room as a specialized procedure facility, not including areas like patient rooms or minor treatment rooms. If the subsequent procedure is related to the original but does not require a return to the operating room, it cannot be billed separately.
CPT guidelines are less specific but emphasize that complications and related services should be reported separately. Coders should verify individual payer policies to ensure correct reporting during the global period.
Modifier 79 - Unrelated Procedure
Modifier 79, "Unrelated Procedure or Service by the Same Physician or Other Qualified Healthcare Professional During the Postoperative Period," is used when a physician performs a procedure unrelated to the initial surgery during the global period of that surgery.
Example of Modifier 79 Use
A patient undergoes a right-eye cataract extraction, reported using code 66984, which includes removing the cataract and inserting an intraocular lens. Later, during the global period of the initial surgery, the patient had a left-eye cataract extraction performed by the same physician. Since the procedures are unrelated (one is for the right eye and the other for the left eye), you should append modifier 79 to the code for the second procedure to indicate that it is distinct and separate from the first.
Using modifier 79 clarifies that although both procedures use the same CPT code, they are performed on unrelated sites, justifying separate reporting and payment.
Modifiers on the MPFS
The last set of modifiers discussed here pertains to the Medicare Physician Fee Schedule (MPFS), funded by Medicare Part B. The MPFS outlines the maximum fees Medicare will reimburse physicians and other healthcare providers fee-for-service. Besides relative value units (RVUs), the MPFS relative value files offer crucial details to apply the following modifiers accurately in Medicare claims.
Modifiers 26 and TC - Professional and Technical Components
Medicare and other payers often differentiate between professional and technical components for certain codes. This is particularly useful for radiologic exams, where different entities typically perform the testing and interpretation functions. For example, CPT® code 71046, which covers a chest radiologic examination with two views, has professional and technical components.
- Modifier 26: This modifier indicates the professional component of a service, which includes the provider's supervision, interpretation, and report.
- Modifier TC: This modifier represents the technical component, covering costs related to technicians, equipment, supplies, and the facility used.
The MPFS relative value files feature a PCTC IND (PC/TC Indicator) column that identifies whether a code can be split into professional and technical components and whether modifiers 26 and TC can be applied. With 10 distinct indicators, coders need to consult it's the current MPFS modifier indicator definitions to use these modifiers correctly.
When reporting a code without modifiers 26 or TC, reimbursement is assumed to cover both components.
A PC/TC split code is called a global code, distinct from the global period and surgical package. The MPFS RVU spreadsheet provides RVUs and indicators for the global code and its components, with the global service rate being the total of the individual component rates.
Modifier 53 - Discontinued Procedure
Modifier 53, which indicates a discontinued procedure, is also covered in the Medicare relative value files. For four colonoscopy codes (44388, 45378, G0105, and G0121), there are separate rows for both the standard code and the code with modifier 53. This setup ensures consistent payment for colonoscopy procedures when modifier 53 is applied.
CPT guidelines suggest using modifier 53 when a scheduled total colonoscopy cannot be completed due to unforeseen issues that prevent the colonoscope from reaching the cecum or colon-small intestine anastomosis.
Modifier 50 - Bilateral Procedure
The MPFS includes a BILAT SURG (Bilateral Surgery) column to show how payment changes for bilateral procedures. According to the Medicare Claims Processing Manual, Chapter 12, Section 40.7, bilateral surgeries are those performed on both sides of the body in the same operative session or day.
To indicate a bilateral procedure, you can use modifier 50 Bilateral procedure. However, MACs may use various methods for reporting bilateral procedures, including modifier 50, modifiers RT (Right side) and LT (Left side), or reporting the procedure twice (2 units).
When modifier 50 is used, or the procedure is reported twice on the same day, the payment adjustment is 150% of the fee schedule amount for a single code. This adjustment is applied based on the lower total actual charge for both sides or 150% of the fee schedule amount. If the bilateral procedure is reported with other codes on the same day, the bilateral adjustment is applied before considering multiple procedure rules.
Modifier 51 - Multiple Procedures
The MULT PROC (Multiple Procedure) column in the Medicare relative value files relates to modifier 51 Multiple procedures. However, many MACs and other payers may direct you not to use modifier 51. Instead, these payers apply the multiple-procedure fee reduction rules based on the codes reported and the MULT PROC indicators assigned to each code.
For payers that do not accept modifier 51, the MULT PROC column provides information on expected payment rather than instructions on modifier use. For instance, Medicare defines multiple-procedure indicator “2” as follows:
2: Standard payment adjustment rules for multiple procedures apply. When a procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50%, and by report). Payment is based on the lower actual charge or the fee schedule amount reduced by the appropriate percentage.
Pre-Op, Intra-Op, and Post-Op Modifiers
The MPFS splits the work required for a surgery into the PRE OP (Preoperative Percentage), INTRA OP (Intraoperative Percentage), and POST OP (Postoperative Percentage) columns. These columns show how much of the fee each portion of the surgical work earns in cases where the same provider is not responsible for every aspect of care.
To alert the payer that different providers are involved, CPT® provides these modifiers:
- 54: Surgical care only
- 55: Postoperative management only
- 56: Preoperative management only
Review payer rules for the proper use of these modifiers. For instance, the Medicare Global Surgery Booklet clarifies that modifier 55 is appropriate only when there has been a transfer of care. You’ll use the surgery date as the date of service and can only use the modifier if the code has a global period of 10 days or 90 days.
Modifiers for Multiple Surgeons
The MPFS relative value files include columns to outline Medicare’s policies on modifier use and payment when multiple providers are involved in a procedure performed during the same session.
Co-surgeons: The CO-SURG (Co-surgeons) column relates to modifier 62 Two surgeons. According to Medicare’s Global Surgery Booklet, modifier 62 is used in the following scenarios:
- A procedure requires two physicians from different specialties, each of whom reports the code with modifier 62.
- Two surgeons perform distinct parts of a procedure, such as in a heart transplant or bilateral knee replacements, with each surgeon reporting the code with modifier 62.
Surgical Team: The TEAM SURG (Team Surgery) column is associated with modifier 66 Surgical Team. This modifier applies when a procedure involves more than two surgeons from different specialties. Each surgeon bills the code with modifier 66.
Assistant at Surgery: The ASST SURG (Assistant at Surgery) column addresses the following modifiers:
- 80: Assistant surgeon
- 81: Minimum assistant surgeon
- 82: Assistant surgeon (when a qualified resident surgeon is not available)
- AS: Services by physician assistants, nurse practitioners, or clinical nurse specialists as assistants at surgery
The ASST SURG indicator indicates whether payment for an additional provider is allowed, not allowed, or possibly allowed with supporting documentation.
For co-surgeons using modifier 62, Medicare pays 62.5% of the global surgery fee for each surgeon. For team surgeries with modifier 66, the Global Surgery Booklet states that claims must provide sufficient information for the MAC to determine pricing “by report.” For assistant-at-surgery services provided by physicians, Medicare’s payment rate is 16% of the surgical fee. These examples highlight the importance of accurate modifier use for precise coding and payment.
CPT and HCPCS Level II Modifier FAQs
Can You Use Modifiers on CPT Add-On Codes?
Modifiers can be used with CPT® add-on codes (noted with a +) in specific situations. Still, it's essential to verify that the modifier is suitable for the add-on code being reported. Here are some examples:
- Modifier 26 and TC: For add-on code +74248 (Radiologic small intestine follow-through study, including multiple serial images), it is appropriate to use modifier 26 (Professional component) or TC (Technical component) if only one of these components is being reported for the service.
- NCCI PTP Edits: Some add-on codes are included in NCCI PTP edit pairs. For example, +22845 (Anterior instrumentation; 2 to 3 vertebral segments) is a column 2 code for +22853 (Insertion of the interbody biomechanical device(s)), as seen in the third-quarter 2022 edits. With a modifier indicator of “1,” you can bypass the edit using associated NCCI PTP modifiers. Generally, add-on codes are not included in NCCI PTP edits because if the primary code edit prevents payment, the add-on code will also be affected, rendering separate edits unnecessary.
However, there are situations where a specific modifier should not be used with an add-on code:
- Modifier 50: According to CPT® guidelines, modifier 50 (Bilateral procedure) should not be used with add-on codes. If the add-on procedure can be performed bilaterally, it should be reported twice if applicable unless the code’s descriptor or guidelines specify otherwise.
Can You Use CPT® Modifiers on HCPCS Level II Codes and Vice Versa?
Modifiers from one code set (CPT or HCPCS Level II) can be used with codes from the other, and this practice is expected. However, it’s essential to check the relevant rules to ensure that the specific modifier is appropriate for the code being reported.
For example, modifier QW (CLIA waived test) is an HCPCS Level II modifier that indicates a test has waived status under the Clinical Laboratory Improvement Amendments (CLIA). The CMS list of CLIA-waived tests includes many CPT lab codes that can be reported with modifier QW, along with a few HCPCS Level II codes. Since this list is regularly updated, it's crucial to check online for the most current information.
Can You Append More Than One Modifier to a CPT or HCPCS Level II Code?
It is often appropriate to append multiple modifiers, including both CPT and HCPCS Level II, to a single code.
For example, you might need to use CPT modifier 22 (Increased procedural services) along with HCPCS Level II modifier LT (Left side) for a procedure performed on the left side of the body.
Claim forms are designed to accommodate multiple modifiers. Still, suppose payer rules, the number of required modifiers, or space constraints on the form necessitates it. In that case, you can use modifier 99 (Multiple modifiers) to indicate that more than four modifiers are being used. Additional modifiers may be listed in another claim form section, such as CMS 1500 box 19.
What Is the Difference Between Modifier 52 and Modifier 53?
Pro-fee coders might need to decide between modifier 52 (Reduced services) or modifier 53 (Discontinued procedure) when a provider does not complete the entire procedure or service described by the code.
According to Appendix A of the AMA CPT code book, modifier 52 is used when a provider chooses to partially reduce or eliminate a service or procedure based on their discretion.
Modifier 53 should be used when a provider terminates a surgical or diagnostic procedure due to extenuating circumstances or situations that could jeopardize the patient's well-being. It is not applicable for elective cancellations of procedures before anesthesia induction or surgical preparation.
For outpatient hospitals and ambulatory surgery centers (ASCs), modifiers 73 and 74 are used instead. Modifier 73 is for procedures discontinued before anesthesia is administered, and modifier 74 is for those stopped after anesthesia. These modifiers are applicable only when the procedure is halted due to extenuating circumstances or patient safety concerns.
When Should You Use Repeat Modifiers 76 and 77?
Modifier 76, Repeat procedure or service by the same physician or other qualified health care professional, should be used when the same provider repeats a procedure or service after the original one. Note that payers, including Medicare, may require physicians of the same specialty within the same group to bill as if they are a single provider.
Modifier 77, Repeat procedure by another physician or other qualified health care professional, is used when a different provider repeats a procedure or service following the original one.
According to Appendix A of the AMA CPT code book, neither modifier 76 nor 77 should be used on an E/M code.
Additionally, payers may have specific guidelines. For example, WPS Government Health Administrators clarifies that modifier 76 should be applied to repeat procedures on the same day.
What Are the ABN Modifiers (GA, GX, GY, GZ)?
An Advance Beneficiary Notice of Noncoverage (ABN) informs a Medicare beneficiary that an item or service may not be covered by Medicare. The beneficiary can then decide whether to proceed, knowing they may be responsible for the cost.
Here are the ABN claim reporting modifiers, as explained in the MLN booklet Medicare Advance Written Notices of Noncoverage:
Modifier GA: Waiver of liability statement issued as required by payer policy, individual case.
- Use modifier GA when you issue a mandatory ABN for a service and the ABN is on file. There's no need to submit the ABN to Medicare, but it must be available upon request. Apply this modifier when the claim includes covered and noncovered services related to an ABN.
Modifier GX: Notice of liability issued, voluntary under payer policy.
- Use modifier GX when you issue a voluntary ABN for a service that Medicare never covers because it's statutorily excluded or not a Medicare benefit. This modifier can be used with the modifier GY.
Modifier GY: Item or service statutorily excluded, does not meet the definition of any Medicare benefit, or, for non-Medicare insurers, is not a contract benefit.
- Use modifier GY when Medicare statutorily excludes the item or service or when the service does not meet the definition of any Medicare benefit. It can be combined with the modifier GX.
Modifier GZ: Item or service expected to be denied as not reasonable and necessary.
- Use modifier GZ when you expect Medicare to deny payment for an item or service because it is not medically necessary and you did not issue an ABN.
Is Drug-Waste Modifier JW Only for Medicare?
No, modifier JW (Drug amount discarded/not administered to any patient) is not exclusively for Medicare claims. While Medicare provides specific guidelines for using this HCPCS Level II modifier, many other third-party payers may also accept it. It's essential to check each payer's policy to confirm whether they accept modifier JW and follow Medicare's rules.
For example, Medicare mandates that modifier JW be used only with drugs designated as single-use or single-dose by the FDA. When billing Medicare, the amount of the drug administered is reported on one line, and the amount discarded is reported on a separate line with modifier JW. The Medicare Claims Processing Manual, Chapter 17, Section 40 gives the scenario where a single-use vial containing 100 units is used, 95 units administered and 5 units discarded. In this case, you would report the 95 units on one line and the 5 discarded units on a separate line with modifier JW appended to the supply code.
Non-Medicare payers may adopt similar practices, so reviewing specific payer guidelines is advisable when using modifier JW.
When Should You Use Modifier KX?
Modifier KX, "Requirements specified in the medical policy have been met," is suitable for various claims, such as:
- Outpatient therapy: Physical, occupational, or speech therapy, notably when exceeding the Medicare threshold.
- DMEPOS: Durable medical equipment, prosthetics, orthotics, and supplies, indicating that coverage criteria and documentation requirements are met.
- Gender-specific services: Used for transgender, intersex, or patients with ambiguous genitalia to bypass gender-specific edits.
In each case, modifier KX signals that necessary conditions are satisfied and supports claim processing.
When Should You Use Hospice Modifiers GV and GW?
The hospice modifiers are GV and GW:
- Modifier GV is used when the attending physician is not employed or paid under an arrangement by the patient's hospice provider. Before using this modifier, ensure that the patient is enrolled in hospice, the hospice does not employ the provider, and the provider was identified as the attending physician when the patient enrolled in hospice.
- Modifier GW is used when the provider renders a service to a hospice patient and the service is unrelated to the patient’s terminal condition. This modifier indicates that the service provided is unrelated to hospice care.
Does Medicare Provide Information About Preventive Services Modifier 33?
Yes, Medicare provides information about modifier 33, which is referenced in the Medicare Claims Processing Manual:
- Section 1.2 and Section 60.1.1 state that coinsurance and deductible are waived for moderate sedation services (reported with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier 33. If a screening colonoscopy becomes diagnostic, moderate sedation services should be reported with only the PT modifier. In this case, only the deductible is waived.
- Section 140.8 mentions that the deductible and coinsurance for advance care planning (ACP) will be waived when billed with modifier 33 on the same day and the same claim as an annual wellness visit (AWV) (codes G0438 or G0439) and must be furnished by the same provider. The waiver is limited to once per year. If the AWV billed with ACP is denied for exceeding the annual limit, the deductible and coinsurance will be applied to the ACP.
What Is the Difference Between Telemedicine Modifiers 95 and GT?
The difference between telemedicine modifiers 95 and GT lies primarily in their usage and payer requirements:
Modifier 95
This modifier denotes that a synchronous telemedicine service was performed via real-time interactive audio and video telecommunications. It is commonly used on professional claims to indicate that the service was a telehealth service. Various payers, including Medicare, widely accept it for telehealth services provided in outpatient settings.
Modifier GT
This modifier indicates a telemedicine service was provided via interactive audio and video telecommunications systems. It is typically used on institutional claims, especially for distant site services billed under the Critical Access Hospital (CAH) method II. Medicare uses modifier GT in institutional settings, while POS 02 is used on professional claims to identify telehealth services.
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