HCPCS Level II Modifiers

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.