HCPCS
Level II Modifiers:
Modifier - as the name implies these are the two digit code that
modifies a service / procedure or an item under certain circumstances. Modifiers
may add information or change the description according to the physician
documentation to give more specificity for the service or procedure rendered.
Appending of an appropriate modifier will effectively respond to reimbursement.
Level II Modifiers: Normally known as HCPCS Modifiers and consists of
two digits (Alpha / Alphanumeric characters) in the sequence AA through VP.
These modifiers are annually updated by CMS - Centres for Medicare and Medicaid
Services.
The above levels of Modifiers are recognized nationally.
AA - Anesthesia services personally
performed by anesthesiologist.
AD - Medical
supervision by a physician: More than 4 concurrent anesthesia procedures.
AE - Registered Dietician
AF - Specialty Physician
AG - Primary Physician
AH - Clinical Psychologist
AI - Principal Physician of Record
AJ - Clinical Social Worker
AK - Non Participating Physician
AM - Physician, team member service
AP - Determination of refractive
state was not performed in the course of diagnostic ophthalmological
examination.
AQ - Service performed in a Health
Professional Shortage Area
AR - Physician providing services in a physician scarcity area
AS - Physician Assistant, Nurse
Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery,
non-team member.
AT - Acute treatment (chiropractic
claims) - This modifier should be used when reporting CPT codes 98940, 98941,
98942 or 98943 for acute treatment.
AX - Item furnished in conjunction
with dialysis services
AY - Item or service furnished to an
ESRD patient that is not for the treatment of ERSD
AZ - Physician providing a service
in a dental Health Professional Shortage Area for the purpose of an Electronic
Health Record Incentive Payment
A1 - Dressing for one wound
A2 - Dressing for two wounds
A3 - Dressing for three wounds
A4 - Dressing for four wounds
A5 - Dressing for five wounds
A6 - Dressing for six wounds
A7 - Dressing for seven wounds
A8 - Dressing for eight wounds
A9 - Dressing for nine or more
wounds
BA - Item furnished in conjunction
with parenteral enteral nutrition (PEN) services
BL - Special Acquisition of blood
and blood products
CA - Procedure payable only in the
inpatient setting when performed emergently on an outpatient who expires prior
to admission.
CB - Services ordered by a dialysis
facility physician as part of the ESRD beneficiary's dialysis benefit.
CC - Procedure code change- CARRIER
USE ONLY - Used by carrier to indicate that the procedure code submitted was
changed either for administrative reasons or because an incorrect code was
filed.
Automated Multi-Channel Chemistry (AMCC) Tests
Modifiers - Effective date: Claims processed on or after April 5, 2010
CD – AMCC test has been ordered by
an ESRD facility or MCP physician that is part of the composite rate and is not
separately billable.
CE – AMCC tests has been ordered by
an ESRD facility or MCP physician that is a composite rate test but is beyond
the normal frequency covered under the rate and is separately reimbursable
based on medical necessity.
CF – AMCC tests has been ordered by
an ESRD facility or MCP physician that is not part of the composite rate and is
separately billable.
Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM6683.pdf
CR - Catastrophe/Disaster Related
CS - Item or service related, in
whole or in part, to an illness, injury, or condition that was caused by or
exacerbated by the effects, direct or indirect, of the 2010 oil spill in the
Gulf of Mexico, including but not limited to subsequent clean-up activities.
DA - Oral health assessment by a
licensed Health Professional other than a dentist
EA
- Erythropetic
stimulating agent (ESA) administered to treat anemia due to anti-cancer
chemotherapy.
EB - Erythropetic
stimulating agent (ESA) administered to treat anemia due to anti-cancer
radiotherapy.
EC - Erythropetic
stimulating agent (ESA) administered to treat anemia not due to anti-cancer
radiotherapy or anti-cancer chemotherapy.
ED - Hematocrit level has exceeded
39% (or Hemoglobin level has exceeded 13.0 G/DL) for 3 or more consecutive
billing cycles immediately prior to and including the current cycle
EE - Hematocrit level has not
exceeded 39% (or Hemoglobin level has not exceeded 13.0 G/DL) for 3 or more
consecutive billing cycles immediately prior to and including the current
cycle.
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)
ET - Emergency treatment - Use to
designate a dental procedure performed in an emergency situation.
FA - Left hand, thumb
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
FB - Item provided without cost to
provider, supplier or practitioner, or credit received for replaced device
(examples, but not limited to covered under warranty, replaced due to defect,
free samples)
FC - Partial credit received for
replaced device
G7 - Pregnancy resulted from rape or
incest or pregnancy certified by physician as life threatening
GA - Waiver of liability statement
on file - Use to indicate that the physician's office has a signed advance notice
retained in the patient's medical record.The notice is for services that may be
denied by Medicare.
GC - This service has been performed
in part by a resident under the direction of a teaching physician.
GD - Units of service exceeds
medically unlikely edit value and represents reasonable and necessary services.
GE - This service has been performed by a resident without the presence of
a teaching physician under the primary care exception.
GG - Diagnostic Mammography - Use to
indicated performance and payment of a screening mammography and diagnostic
mammography on same patient, on the same day.
GH - Diagnostic mammogram converted
from screening mammogram on same day
GJ - Opted Out physician or
practitioner - Use to indicate services performed in an emergency or urgent
service.
GM - Multiple patients on one
ambulance trip
GN - Services delivered under an
outpatient speech language pathology plan of care.
GO - Services delivered under an
outpatient occupational therapy plan of care.
GP - Services delivered under an
outpatient physical therapy plan of care.
GQ - Telehealth services via
asynchronous telecommunications system
GR - This service was performed in
whole or in part by a resident in a department of Veterans Affairs Medical
Center or clinic supervised in accordance with VA policy.
GS - Dosage of EPO or Darbepoietin
Alfa has been reduced and maintained in response to hematocrit or hemoglobin
level.
GT - Telehealth services via
interactive audio and video telecommunication systems
GU - Waiver of liability statement issued
as required by a payer policy, routine notice
GV - Attending physician not
employed or paid under agreement by the patient's hospice provider.
GW - Service not related to the
hospice patient's terminal condition.
GY - Use to indicate when an item or
service statutorily excluded or does not meet the definition of any Medicare
benefit.
GZ - Use to indicate when an item or
service expected to be denied as not reasonable and necessary.Used when no
Advanced Beneficiary Notice (ABN) signed by the beneficiary.
J1 - Competitive Acquisition
Program, no-pay submission for a prescription number
J2 - Competitive Acquisition
Program, restocking of emergency drugs after emergency administration
J3 - Competitive Acquisition
Program, (CAP) drug not available through CAP as written, reimburse under ASP
Methodology
JA - Administered intravenously
JB - Administered subcutaneoulsly
JC - Skin substitute used as a graft
JD - Skin substitute NOT used as a
graft
KB - Beneficiary requested upgrade
for ABN, more than 4 modifiers identified on claim
KC - Replacement of special power
wheelchair interface
KD - Drug or Biological infused
through implanted DME
KE - Bid under round one of the
DMEPOS competitive bidding program for use with non-competitive bid base
equipment
KF - Item designated by FDA as Class
III device
KM - Replacement of
facial prosthesis - including new impression/moulage
KN - Replacement of facial
prosthesis - Using previous master model
KX - Specific required documentation
on file (used for DMERC providers)
KZ - New Coverage not implemented by
managed care
LC - Left circumflex coronary artery
LD - Left anterior descending
coronary artery
LR - Laboratory Round Trip.
LT - Left Side - Used to identify
procedures performed on the left side of the body.
M2 - Medicare Secondary Payer
NB - Nebulizer system, any type,
FDA-Cleared fo ruse with specific drug
NU - New
equipment (DME)
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
PA - Surgery Wrong Body
Part
PB - Surgery Wrong
Patient
PC - Wrong Surgery on Patient
Please refer http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6718.pdf for proper usage of PA, PB and PC Modifiers
PD - Diagnostic or related
non-diagnostic item or service provided in a wholly owned or wholly operated
entity to a patient who is admitted as an inpatient within 3 days, or 1 day. (New modifier for the year 2012, Check for Usage and
reimbursement)
PI - PET Tumor init tx
strategy
PS - PET Tumor subsq tx strategy
PT - Colorectal cancer screening
test; converted to diagnostic test or other procedure
Q0 -
Investigational clinical service provided in a clinical research study that is
in an approved clinical research study.
Q1 - Routine clinical service
provided in a clinical research study that is in an approved clinical research
study.
Q3 - Liver Kidney Donor
Surgery and Related Services.
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
Q7 - One CLASS A finding
Q8 - Two CLASS B findings
Q9 - One CLASS B and two CLASS C
findings
QA - FDA Investigational device
exemption (IDE) - The IDE project number must be included on the claim when
modifier QA is billed.
QB - Physician service in a rural
HPSA.
QC - Single channel monitoring.
QD - Recording and storage in solid
state memory by a digital recorder.
QJ - Services/items provided to a
prisoner or patient instate or local custody.
QK - Medical direction of 2, 3 or 4 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 - Panel test - Documentation is on file showing that the
laboratory test(s) was ordered individually or ordered as a CPT-recognized
panel other than automated profile codes.
QS - Monitored anesthesia care
QT - Recording and storage on tape
by an analog tape recorder.
QU - Physician service in an urban
HPSA.
QV - Item or service provided as
routine care in a medical qualifying clinical trial
QW - CLIA Waived Test - Effective
October 1, 1996, all new waived tests are being assigned a CPT code (in lieu of
a temporary five-digit G- or Q-code).
QX - CRNA service with medical
direction by physician.
QY - Medical direction of one certified
registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ - CRNA service without medical
direction by a physician.
RA - Replacement of a
DME item, Orthotic or Prosthetic Item
RB - Replacement of a Part of DME, Orthotic or Prosthetic Item
furnished as Part of a Repair
RC - Right coronary artery
RD - Drug provided to beneficiary, but not, administrated
incident-to
RE - Furnished in full compliance with FDA-Mandated Risk
Evaluation and Mitigation Strategy (REMS)
RP - Replacement and repair
RT - Right Side
- Used to identify procedures performed on the right side of the body.
RR - Rental (use the RR modifier when DME is a rental)
SC - Medically necessary service or supply (w.e.f Jan 1, 2012)
SF - Second opinion ordered by a
Professional Review Organization (PRO) per section 9401, P.L. 99-272 (100 %
reimbursement – no Medicare deductible or coinsurance)
SG - Ambulatory Surgical Center (ASC) modifier
SK - Member of high risk population (Use only with codes for
immunization)
SS - Home infusion services provided
in the infusion suite of the IV therapy provider
SW - Services provided by a
certified diabetes educator
TA - Left foot, great toe
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
TC - Technical component only - Use
to indicate the technical part of a diagnostic procedure performed.
TS - Follow-up
service
UE - Used
durable medical equipment
UN - Portable X-ray
Modifiers; two patients
UP - Portable X-ray Modifiers; three
patients
UQ - Portable X-ray Modifiers; four
patients
UR - Portable X-ray Modifiers; five
patients
US - Portable X-ray Modifiers; six
patients
V1 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or
medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service
is equal to a "minimal" level.
V2 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or
medical disability examination by the treating physician..." CPT code
99455 when the office visit level of service is equal to "self limited or minor"
level.
V3 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or
medical disability examination by the treating physician..." CPT code
99455 when the office visit level of service is equal to "low to
moderate" level.
V4 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or
medical disability examination by the treating physician..." CPT code
99455 when the office visit level of service is equal to "moderate to high
severity" level and of at least 25 minutes duration.
V5 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or
medical disability examination by the treating physician..." CPT code
99455 when the office visit level of service is equal to "moderate to high
severity" level and of at least 45 minutes duration.
V5 - Any Vascular Catheter (alone or with any other
vascular access) - Part A only modifier
V6 - Arteriovenous Graft (or other
vascular access not including a vascular catheter) - Part A only modifier
V7 - Afteriovenous Fistula (or other
vascular access not including a vascular catheter) - Part A only modifier
V8 - Dialysis related infection
present during the billing month - Part A only modifier
V9 - No dialysis related infection
present during the billing month - Part A only modifier
VR - Review report - This
modifier shall be added to the "Work related or medical disability
examination by the treating physician..." CPT code 99455 to indicate that
the service was the treating doctor's review of report(s) only.
Modifier ZA - (Anesthesia
modifier especially used for Medi-cal insurance of California) denotes prone
position or surgical field avoidance. To be used only for procedures that have
a base value of three (3) units. These techniques are included in the
anesthesia base value of surgical procedures with a base value of more than
three.
Modifier ZE -
(Anesthesia modifier especially used for Medi-cal insurance of California) To
be billed with the appropriate five-digit CPT-4 anesthesia code to identify a
normal, uncomplicated anesthesia provided by a Certified Registered Nurse
Anesthetist (CRNA).
Please note: It is also necessary to
check the respective insurance guidelines for appropriate usage of Modifiers to
avoid denials.
