PROVIDER BILLING GUIDELINES

Modifiers

Modifiers are two digit or alphanumeric characters that are appended to CPT and HCPCS codes. The
modifier allows the provider to indicate that a procedure was affected by special circumstances, without
changing the definition of the code.

These codes can serve as informational or as a billing clarification for payment. The use of the correct
modifier is an important part of avoiding fraud and abuse or non-compliance issues. Some can be
easily misused and the modifier grid below should provide guidance on some of the most commonly
billed modifiers.

There are two levels of modifiers: Level 1 (CPT) and Level II (CMS, also known as HCPCS).

Level I (CPT) Modifiers

Level I Modifiers are two numeric digits. The American Medical Association (AMA) updates these annually.

Level II (CMS) Modifiers

Level II Modifiers are two alphanumeric or alpha codes. They are recognized nationally and are updated
annually by CMS.

Code Editing of Modifiers

Code editing software is used to apply National Correct Coding Initiative (NCCI) to edit claims for accurate
usage of claims coding in compliance with CMS and general industry standards. Claims that are coded
incorrectly including the misuse of modifiers are subject to denial. Please refer to the Code Auditing and
Editing section of the Provider Manual for more detailed information about the correct coding edits and the
impact on claims.

Documentation supporting the use of certain modifiers may be requested. Failure to provide the
supporting documentation upon request will results in denials. Item 19 in the CMS 1500 or its
electronic equivalent should reflect that the required documentation for a service is available.

Modifiers Chart

Increased Procedural Services

This code should only be used when the work is significantly greater than typically
required and included in the procedure. Documentation to support the services must
be provided if requested by the payor.
• This code should not be appended to an Evaluation and Management Code.
• Example: If there were significant work involved in the delivery of a second
22 baby for twins that is not covered within the definition of the global maternity
code then modifier 22 would be appended to 59510 or 59618.
• The use of modifier 22 for increased procedural services should be used only
in certain circumstances. Due to the chances of misuse documentation may
be requested to support the use of the code. If the practitioner does not have
the documentation readily available the claim is subject to denial.

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Unusual Anesthesia
There are times where a patient must be put under anesthesia due to a behavioral or
physical concern where anesthesia is typically not used. This must be appended with
a modifier 23.
• Documentation to support the use of the modifier should accompany the claim
submission.
23 • Report in the 2nd modifier position. The first modifier position indicates that
the anesthesia is being personally performed, medically directed, or medically
supervised. (AA, AD, QY, QK, QX) See Guidelines for Anesthesia
• Do not report with codes that are normally performed under general
anesthesia

Unrelated Evaluation and Management

If a postoperative E/M code was performed during a post operative period for reasons
unrelated to the original procedure the provider should append modifier 24. This
will allow the services to be considered separately outside of the global surgical
package for the procedure performed. A different diagnosis should be reported and
documentation provided to support if requested by the payor.
• Used with E/M codes
• Use on an unrelated E/M service beginning the day after the procedure when
the same practitioner performs procedure during the global follow-up period.
• Use if documentation indicates the service was for the underlying condition
24 and not for post operative care
• Use when the same practitioner is managing immunosuppressant therapy
during the postoperative period of a transplant or chemotherapy during the
postoperative period of a procedure.
• When the same practitioner provides unrelated critical care during the
postoperative period.
DO NOT USE WHEN:
• The E/M is for a surgical complication or injection. These are included in the
global surgical fee.
• Do not use on same day as procedure

Significant, Separately Identifiable Evaluation and Management Service by the

Same Physician or Other Qualified Health Care Professional on the same Day of
the Procedure and Other Service
• Patient’s condition must require a significant, separately identifiable
E/M service
25 • If two physicians belong to the same group but have different specialties and
see the same patient on the same day for different conditions Modifier 25
should be used.

Approved for ASC use by AMA and CMS

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Professional Component
Appended to the professional component only of a radiology or lab code.
• To report the practitioners interpretation of the test of the lab or radiology
service
• Do not use when the same provider performs both the professional and
26 technical portions of the procedure
• Do not append to technical only procedure codes, global test codes, or
professional component only codes
• Do not report 26 and TC modifiers on the same procedure code on one line of
service

Multiple outpatient Hospital evaluation and management encounters on the

same date.
27
Approved for ASC use by AMA and CMS

Preventive Visit
Required to indicate the services is in accordance with the Preventative Service
Task Force A or B and other ACA mandated services. Allows the payer to identify
preventative services. If the deductible is to be waived this modifier can be used to
alert the system to waive the deductible.
Modifier 33 is to be used on services other than those that are inherently preventive.
Example: A screening colonoscopy CPT 45378, which results in a polypectomy CPT
33 45388. 45378 is defined as a screening preventive procedure and therefore would not
require the modifier 33 to waive cost sharing. In this situation polyps were identified
during the screening and were removed resulting in a change of codes being used to
reflect the screening and the removal. 45388 would have the modifier 33 appended to
ensure cost share is waived.
Please refer to the Preventive Guidelines for specific use and details of this modifier.

Bilateral Procedure
The bilateral modifier should be used only on those procedure codes not described as
bilateral procedures or services. Only applicable to services or procedures performed
50 on identical anatomical sites, aspects, organs (e.g.. Arms, legs, eyes). It is entered on
one line with the 50 modifier to indicate it was done bilaterally. The number of units
reported should be 1.

Multiple Procedures
Multiple procedures performed by the same provider at the same session should have
the modifier 51 appended to all procedures other than the primary or highest RVU
51 procedure. The 51 triggers the multiple surgery reduction. Modifier 51 should not be
appended to any 51 exempt codes listed in CPT.

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Reduced Services
Reporting by a physician that the scheduled procedure was reduced or eliminated.
• The procedure should be billed with a reduced charge to reflect that services
were reduced or eliminated.
• Do not use for terminated services
• Do not use on time based codes such as anesthesia, critical care
52 • Do not use on E/M or Consultation Codes
• Services will be considered at 50% of base fee unless otherwise stipulated
per contract.

Approved for ASC use by AMA and CMS

Discontinued Services
Surgical procedure was stopped or discontinued due to the risk of the health of the
patient.
• The procedure was stopped after the induction of anesthesia
• Do not use on time based codes such as anesthesia, critical care
53 • Documentation must state that the procedure was started, why it was
discontinued and state the percentage of the procedure performed.
Services will be allowed at 25% of the base fee schedule unless otherwise stipulated
by the contract.

Postoperative Management Only

55 When one physician performs the post operative for a surgeon who performed the
surgery
Physician Performed Preoperative Services Only
56 A physician provided pre-operative care while a surgeon provided the surgery.
Decision for Surgery
This modifier is used with an E/M visit where the decision to perform the surgery is
57 made either the day before or the day of the surgery. The use of the modifier allows
the E/M to be paid and not included in the global surgical package.
Staged or Related Procedure or Service by the Same Physician During The
Postoperative Period
This code indicates that this procedure is related to the primary surgical procedure
and is performed during the global period. It is most often applied when the second
58 procedure was already anticipated but could not be done at the time of the primary
procedure due to the significance of the underlying disease process.

Approved for ASC use by AMA and CMS

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Distinct Procedural Service

E/M performed was distinct or separate from other non E/M services performed on
that day. According to CMS Modifier 59 is used appropriately when:
• When different anatomic sites during the same encounter only when
procedures, which are not ordinarily performed or encountered on the same
day, are performed on different organs, or different anatomic regions or in
limited situations on different non- contiguous lesions in different anatomic
regions of the same organ
• When procedures are performed in different encounters on the same day
• For two services described by time codes provided during the same encounter
only when they are performed sequentially
• For a diagnostic procedure, which precedes a therapeutic procedure only
when the diagnostic procedure is the basis for performing the therapeutic
procedure
• For a diagnostic procedure which occurs subsequent to a completed
therapeutic procedure only when the diagnostic procedure is not a common,
expected, or necessary follow-up to the therapeutic procedure
59
Effective January 1, 2015 modifiers XE, XS, XP, XU should be utilized in the
place of modifier 59 whenever appropriate. Modifier 59 should only be used if
there is no other more specific modifier available.
• XE – “Separate encounter, a service that is distinct because it occurred during
a separate encounter.
• XS – “Separate Structure, A service that is distinct because it was performed
on a separate organ, structure.”
• XP – “ Separate Practitioner, A service that is distinct because it was
performed by a different practitioner.”
• XU – “ Unusual Non-Overlapping Service, the use of a service that is distinct
because it does not overlap usual components of the main service.”

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier.
pdf

Approved for ASC use by AMA and CMS

Two Surgeons/ Co-Surgeons

This is to be used if two surgeons are required to perform a procedure. Both surgeons
62 must bill the same surgery code with modifier 62. Documentation of necessity must
be available. The surgeons may be of different specialties.
Discontinued Outpatient Hospital/Ambulatory Surgery Center ASC Procedure
Prior to the Administration of Anesthesia
Only used if the procedure was cancelled due to a threat to the well being of the
73 patient.

Approved for ASC use by AMA and CMS

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Discontinued Outpatient Hospital/Ambulatory Surgery Center ASC Procedure

After the Administration of Anesthesia or After the Procedure Was Started
(incision made, intubation started, scope inserted.)
74
Approved for ASC use by AMA and CMS

Repeat Procedure or Service by same Physician or Other Qualified Health Care

Professional
• Used when it is necessary to report repeat procedures performed on the same
day.
• Report each on a separate line, using a quantity of 1 and appending 76 to
76 each subsequent service. The first service should not have a 76 modifier.
• Failure to use the 76 will result in the additional procedures being denied.

Approved for ASC use by AMA and CMS

Repeat Procedure or Service by Another Physician or Other Qualified Health

Care Professional
• Append to the professional component of an x-ray or EKG procedure when a
different physician repeated the reading as the physician performing the initial
reading believes another physician’s expertise is needed.
77 • Append to the professional component of an x-ray or EKG when the patient
has two or more tests and more than one physician provides the interpretation
and report.

Approved for ASC use by AMA and CMS

Unplanned Return to the Operating/Procedure Room by the Same Physician

or Other Qualified Health Care Professional Following Initial Procedure for a
Related Procedure During the Postoperative Period
• To treat the patient for complications resulting from the original surgery
78 • This modifier should not be used on procedures performed outside of the
operating room.

Approved for ASC use by AMA and CMS

Unrelated Procedure or Service by the Same Physician or Other

Qualified Health Care Professional During the Postoperative Period
Example: Patient falls after hip surgery and breaks his elbow during the postoperative
period. The fracture repair of the elbow is not related to the hip surgery therefore
79 modifier 79 should be appended to that procedure.

Approved for ASC use by AMA and CMS

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Assistant Surgeon
80 This code is used when one surgeon acts an assistant to another surgeon.

Minimum Assistant Surgeon

This code is used only when the primary surgeon indicated he needs an assistant for
81 a very short time.

Assistant Surgeon (when qualified resident surgeon not available)

Used in teaching hospitals to show that a qualified resident assistant surgeon was not
82 available and a non-resident surgeon assisted.

Reference (Outside) Laboratory

This code is used when laboratory procedures are performed by anyone other than
the treating or reporting physician the procedure may be identified by adding modifier
90 90.
• The outside lab cannot be related the treating or reporting doctor.

Repeat Clinical Diagnostic Laboratory Test

If a test is repeated several times in one day to obtain subsequent results the modifier
91 may be appended.
• Example: same blood tests being performed several times in one day to
91 monitor certain levels.

Approved for ASC use by AMA and CMS

Alternative Laboratory Platform Testing

• A laboratory teat performed using a kit or transportable instrument that consist
of a single use, disposable chamber.
92 • The test does not require permanent dedicated space.
• The test is designed to be carried or transported to the patient for immediate
testing
• Not acceptable for Medicare Part B. Will be rejected.
Multiple Modifiers
Indicates multiple modifiers may be necessary to completely support a service.
In such situations, modifier 99, should be added to the basic procedure and other
99 applicable procedures.
• Report in the first modifier position
• All other modifiers are to go in field 19 of the CMS 1500 or 837P equivalent.

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Anesthesia Modifiers

Anesthesia Services Performed Personally by the Anesthesiologist

AA See Anesthesia Guidelines for further guidance.

Medical Supervision by a Physician;

AD More Than 4 Concurrent Anesthesia Procedures
See Anesthesia Guidelines for further guidance.

Medical Direction of Two, Three, Four Concurrent Anesthesia Procedures

QK See Anesthesia Guidelines for further guidance.

Medical Direction of One CRNA by an Anesthesiologist

QY See Anesthesia Guidelines for further guidance.

CRNA Service: With Medical Direction by a Physician

QX See Anesthesia Guidelines for further guidance.

CRNA Service: Without Medical Direction by a Physician

QZ Involving Qualified Individuals

Separate Encounter, a Service That Is Distinct Because It Occurred

XE* During a Separate Encounter
Effective 1/1/2015. Use in place of Modifier 59. See Modifier 59.

Separate Structure, a Service That Is Distinct Because It Was Performed

XS* on a Separate Organ, Structure
Effective 1/1/2015. Use in place of Modifier 59. See Modifier 59.

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Separate Practitioner, a Service That Is Distinct Because It Was

XP* Performed by a Different Practitioner
Effective 1/1/2015. Use in place of Modifier 59. See Modifier 59.

Unusual Non-Overlapping Service

The use of a service that is distinct because it does not overlap
XU* usual components of the main service.
Effective 1/1/2015. Use in place of Modifier 59. See Modifier 59*

*http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier.pdf

Level II (CMS) modifiers are used to provide additional specification to a procedure being performed
including but not limited to the following:
• Anatomical location a procedure is performed. (e.g. E 1 – E2 Upper left and lower left eyelid)
• Measurements (e.g. QE-prescribed amount of oxygen is less than 1 liter per minute)
• Type of provider specialty (e.g. QZ – CRNA service without medical direction of a physician)
• Type of service (e.g. QN -Ambulance Service furnished directly by a provider of service)

CMS modifiers can impact the accuracy of the payment of the claim as well as provide information about
the patient or provider for data purposes. Accurate reporting of these modifiers should be used to provide
the specificity to procedures performed as required. Failure to do so may result in denials or erroneous
payments.

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