Reimbursement Policy Modifier Reference Guide This document is a reference guide to provide information regarding modifiers related to Medica reimbursement policies. The use of modifiers is an important component of billing health care services. Under certain circumstances, procedure codes can be modified to provide a more accurate representation of the service rendered. Refer to the reimbursement policies listed for each modifier to obtain additional information. Note: The list below represents many modifiers that are addressed in Medica reimbursement policies. It is not an all-inclusive list of CPT and HCPCS modifiers. Modifier Description Refer to Reimbursement Policy 22 Increased Procedural Service Increased Procedural Services, Obstetrical 23 Unusual Anesthesia Anesthesia 24 Unrelated Evaluation and Anesthesia, Global Days Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period 25 Significant, Separately Identifiable Anesthesia, CCI Editing, Global Days, Injection Evaluation and Management Service and Infusion Services, Obstetrical, Preventive Medicine and Screening, Rebundling, Same Day by the Same Physician or Other Same Service Qualified Health Care Professional on the Same Day of the Procedure or Other Service 26 Professional Component Professional and Technical Components 50 Bilateral Procedure Bilateral Procedures, Co-Surgeon/Team Surgeon, One or More Sessions 51 Multiple Procedure Multiple Procedure Reduction, Obstetrical 52 Reduced Services Bilateral Procedures, One or More Sessions, Reduced Services 53 Discontinued Procedure Discontinued Procedure, Once in a Lifetime Procedures, One or More Sessions 54 Surgical Care Only One or More Sessions, Split Surgical Package 55 Postoperative Management Only One or More Sessions, Once in a Lifetime Procedures, Split Surgical Package 56 Preoperative Management Only One or More Sessions, Once in a Lifetime Procedures, Split Surgical Package 57 Decision for Surgery Global Days 58 Staged or Related Procedure or Global Days, Once in a Lifetime Procedures Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period 59 Distinct Procedural Service Anesthesia, CCI Editing, Laboratory Services, Maximum Frequency per Day (Units), Obstetrical, Rebundling Reimbursement Policy Modifier Reference Guide Page 1 of 4 Modifier 62 63 Description Two Surgeons Procedure Performed on Infants less than 4kg Surgical Team Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional 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 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period Assistant Surgeon Minimum Assistant Surgeon Assistant Surgeon (when qualified resident surgeon not available) Refer to Reimbursement Policy Co-Surgeon/Team Surgeon Increased Procedural Services 90 Reference (Outside) Laboratory Laboratory Services 91 Repeat Clinical Diagnostic Laboratory Test Alternative Laboratory Platform Testing Anesthesia services performed personally by an anesthesiologist. Medical supervision by a physician: more than four concurrent anesthesia procedures. Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Service for Assistant at Surgery Via interactive audio and video telecommunication system Drug amount discarded/not administered to any patient Left side A normal healthy patient Laboratory Services, Maximum Frequency per Day (Units) Laboratory Services 66 76 77 78 79 80 81 82 92 AA AD AS GT JW LT P1 Reimbursement Policy Modifier Reference Guide Co-Surgeon/Team Surgeon Laboratory Services, Maximum Frequency per Day (Units) Laboratory Services Anesthesia, Global Days, Multiple Procedure Reduction Global Days, One or More Sessions Assistant Surgeon Assistant Surgeon Assistant Surgeon Anesthesia Anesthesia Assistant Surgeon Telehealth Discarded Drugs and Biologicals Bilateral Procedures, One or More Sessions Anesthesia Page 2 of 4 Modifier P2 P3 P4 P5 P6 QK QX QY QZ RT TC XE XP XS XU Revision Updates 01/01/2015 08/24/2014 08/01/2013 01/01/2013 Description A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life. A moribund patient who is not expected to survive without the operation. A declared brain-dead patient whose organs are being removed for donor purposes Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. Qualified nonphysician anesthetist with medical direction by a physician Medical direction of one qualified nonphysician anesthetist by an anesthesiologist CRNA service; without medical direction by a physician. Right side Technical Component Separate Encounter: A service that is distinct because it occurred during a separate encounter Separate Practitioner: A service that is distinct because it was performed by a different practitioner Separate Structure: A service that is distinct because it was performed on a separate organ/structure Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service Refer to Reimbursement Policy Anesthesia Anesthesia Anesthesia Anesthesia Anesthesia Anesthesia Anesthesia Anesthesia Anesthesia Bilateral Procedures, One or More Sessions Professional/Technical Component Anesthesia, CCI Editing, Laboratory Services, Maximum Frequency per Day (Units), Obstetrical, Rebundling Anesthesia, CCI Editing, Laboratory Services, Maximum Frequency per Day (Units), Obstetrical, Rebundling Anesthesia, CCI Editing, Laboratory Services, Maximum Frequency per Day (Units), Obstetrical, Rebundling Anesthesia, CCI Editing, , Maximum Frequency per Day (Units), Obstetrical, Rebundling XE, XP, XS, XU modifiers added One or More Sessions policy added to 79 modifier; Telehealth policy modifier added JW modifier added Annual code update Reimbursement Policy Modifier Reference Guide Page 3 of 4 © 2011-2015 Medica. Medica® is a registered service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC Reimbursement Policy Modifier Reference Guide Page 4 of 4
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