Professional Documents
Culture Documents
For Medicare purposes, modifiers are two-digit codes appended to procedure codes, to provide
additional information about the billed procedure. In some cases, addition of a modifier may directly
affect payment. Below is a list of modifiers including the modifier description.
Modifiers that are used on claims for ambulance services are created by combining two alpha characters.
Each alpha character, with the exception of X, represents an origin (source) code or a destination code.
The pair of alpha codes creates one modifier. The first position alpha code = origin; the second position
alpha code = destination.
Origin and destination codes and their descriptions are listed below:
D Diagnostic or therapeutic site other than "P" or "H" when these are used as origin codes
E Residential, domiciliary, custodial facility, nursing home
G Hospital based dialysis facility (hospital or hospital related)
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
J Non-hospital based dialysis facility
N Skilled nursing facility (SNF) (Medicare certified beds)
P Physician’s office (includes HMO non-hospital facility, clinic, etc.)
R Residence
S Scene of accident or acute event
X (Destination code only) Intermediate stop at physician’s office en route to the hospital (includes
HMO non-hospital facility, clinic, etc.)
QL Patient Pronounced dead after ambulance called
The following modifiers are valid for Medicare; however, the services would be denied under Medicare
Part B as a Part A expense.
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Billing indicators, listed below, can be used to further clarify the services provided. These billing
indicators may be used as additional modifiers.
1A Bedridden
2A Accidental injury home/nursing home
3A Accidental injury car
4A Patient in shock
5A Oxygen used and/or heart monitor used
6A Transported by stretcher
7A Fracture to hip, leg, knee, trunk (same day as ambulance trip)
8A Hospital lacks facility (patient admitted to second hospital)
9A Rectal bleeding
1B Myocardial infarction
2B Possible cerebral vascular accident (CVA)
3B Black out, passed out
4B Laceration of head
5B Dead on Arrival (DOA) at hospital
6B Died in route to hospital
7B Unresponsive or coma
8B Quadriplegia
9B Stroke (same day as ambulance trip)
1C Paralysis
2C Mentally retarded
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ANCILLARY PERSONNEL MODIFIERS
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AMBULATORY SURGICAL CENTER MODIFIERS
26 Professional component only - Use to indicate that the physician component is reported separately
from the technical component for the diagnostic procedure performed
90 Reference Lab - Used to indicate a lab test sent to an outside lab. e.g., lab procedure performed by a
party other than the treating or reporting laboratory. NOTE: Outside lab name, address and UPIN
must be included on the claim. Section 20 must be marked "yes" and your actual cost for each test,
net any discounts, must be included in the charges section.
GH Diagnostic mammogram converted from screening mammogram on the same day.
QP 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
QR Repeat clinical diagnostic laboratory test performed on the same day to obtain subsequent
reportable test value(s) (separate specimens taken in separate encounters)
QW CLIA waived test
TC Technical component only - Used to indicate that the technical component is reported separately
from the professional component for the diagnostic procedure performed
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21 Prolonged evaluation and management services - Use only with highest level of care code for the
category when the face-to-face or floor/unit service provided is prolonged or otherwise greater than
that usually required for the highest level code.
24 Unrelated E/M service during a post-op period - Use with E/M codes only to indicate that the E/M
performed during a postoperative period for a reason(s) unrelated to the original procedure. Modifier
24 applies to unrelated E/M services for either a MAJOR or MINOR surgical procedure.
- Failure to use modifier when appropriate may result in denial of the E/M service
25 Separately identifiable service on same day as procedure - Use with E/M codes only to indicate that
the patient’s condition required a significant, separately identifiable E/M service above and beyond
the other service provided or beyond the usual pre- and postoperative care for the procedure
performed
- Failure to use modifier when appropriate may result in denial of the E/M service
57 Decision for surgery - Use with E/M codes billed by the surgeon to indicate that the E/M service
resulted in the decision for surgery (E/M visit was NOT usual pre-operative care). For E/M visits
prior to MAJOR surgery (90 day post-op period) only.
- Failure to use modifier when appropriate may result in denial of the E/M service
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SURGICAL PROCEDURE MODIFIERS
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77 Repeat procedure - same day, different physician
78 Return to the operating room for a related procedure during the postoperative period - Use on
surgical codes only.
- Failure to use modifier when appropriate may result in denial of the subsequent surgery
79 Return to the operating room for an unrelated procedure during the postoperative period - Use on
surgical codes only.
80 Assistant surgeon
81 Minimum assistant surgeon
82 Assistant surgeon (when qualified resident surgeon not available)
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SURGICAL PROCEDURE EXPANDED MODIFIERS: HANDS - FEET - EYELIDS
The following modifiers should be used in conjunction with procedures of the hands, feet and eyelids.
The modifiers will not effect payment; however, failure to use these modifiers when appropriate could
result in claim delay or denial.
AT Acute treatment - this modifier should be used when reporting service A2000 for acute treatment
CC Procedural 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. The
remittance statement will indicate the "submitted" code as well as the "new" code used by the
carrier.
EJ Subsequent claim for Epoetin Alfa-EPO- injection claim only
EM Emergency reserve supply (for ESRD benefit only)
ET Emergency treatment - Use to designate a dental procedure performed in an emergency situation
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
- No effect on payment; however, potential liability determinations are based in part on the use of
the modifier
LR Laboratory Round Trip
QA Investigational device or related procedure
QB Physician service in a rural HPSA
QC Single channel monitoring
QD Recording and storage in solid state memory by digital recorder
QT Recording and storage on tape by an analog tape recorder
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QU Physician service in an urban HPSA
Q3 Live Kidney Donor - Use for services associated with postoperative medical complications directly
related to the donation
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
99 Multiple modifiers - Use only when more than two modifiers are needed to describe a service. File
hard copy.
- No effect on payment; however, the individual modifiers listed will apply, including any potential
effect they may have on payment.
ZX DMERC modifier to identify insulin-dependent beneficiary
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Y5 Fourth repeat procedure, same date, same provider
Y6 Fifth repeat procedure, same date, same provider
Y7 Sixth repeat procedure, same date, same provider
Y8 Seventh repeat procedure, same date, same provider
Y9 Eighth repeat procedure, same date, same provider
Z2 Ninth repeat procedure, same date, same provider
Z3 Tenth repeat procedure, same date, same provider
Z5 No purchased diagnostic services on this claim
Z6 Pre-anesthesia services up to and including induction when personally furnished by the physician.
Payment is based on 3 units and 1 time unit.
Note: In addition to the standard modifiers indicating whether the claim is for the professional
component only or the technical component, a two-digit modifier should be used to indicate the results
of the PET scan and the previous test. The modifier is not required for the technical component - only
billings to the intermediary. The first alpha character is used to indicate the results of the PET scan while
the second alpha character indicates the results of the prior test. The test result modifiers and their
descriptions are listed below:
N Negative
E Equivocal
P Positive, but not suggestive of extensive ischemia
S Positive and suggestive of extensive ischemia (greater than 20% of the left ventricle)
Billing indicators, listed below, can be used to further clarify the services provided. These billing
indicators should be used as additional modifiers.
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