Subject: Modifier Rules CT Policy: 0017 Effective: 11/18/2017 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. This reimbursement policy also applies to Employer Group Retiree Medicare Advantage programs. Description A modifier is made up of a two-digit alpha/numeric character that is appended to a Current Procedural Terminology (CPT ) or Healthcare Common Procedure Coding System (HCPCS Level II) code. It is used as a means of reporting a specific circumstance that further defines or alters the code but it does not change the definition of the procedure performed or item procured. Policy The Health Plan accepts for claims processing, but not necessarily for compensation, all HIPAA compliant CPT and HCPCS modifiers. The Health Plan treats some modifiers as informational only ; some modifiers are important to the adjudication of the claim; and some modifiers may affect the of the maximum allowable amount (MAA). Providers must follow proper coding guidelines as set by CPT or The Centers for Medicare & Medicaid Services (CMS) when reporting modifiers The Health Plan also uses ClaimsXten for modifier to procedure code validation. ClaimsXten identifies if a modifier is inappropriately used with a procedure code. When an invalid modifier to procedure code combination is detected, the line item will be denied, requesting that the correct code and modifier be resubmitted. The Health Plan validates that the following modifiers are appropriately used with procedure codes: 22, 23, 24, 25, 26, 27, 50, 52, 53, 54, 55, 56, 57, 59, 62, 63, 73, 74, 76, 77, 78, 79, 80, 81, 82, 91, 92, 95, AA, AD, AS, BP, BR, CT, E1-E4, EX, F1-F9, FA, KC, KI, KR, LC, LD, LL, LM, LT, MS, NR, NU, P3, P4, P5, QK, QX, QY, QZ, RA, RB, RC, RI, RR, RT, T1-T9, TA, TC, UE XP, XS, and XU. When multiple procedures are performed on the same date of service and one line includes a site specific modifier, the Health Plan requires that all subsequent procedure codes also include a site specific modifier when applicable. When only one line is reported with a site specific modifier and subsequent lines are reported without a site specific modifier the Health Plan may consider the additional procedure(s) to be same site as the modified procedure which may result in the subsequent procedure(s) being denied. When multiple modifiers that apply a amount to the MAA are reported with a procedure, ClaimsXten will multiply the amounts together to determine a new amount. When the new amount contains a decimal place, ClaimsXten round the new amount up to the next whole and apply this whole amount to the MAA for the procedure the modifiers are reported with. For example, modifier 78 (unplanned return to the operating/procedure room) applies a of 70% and modifier 62 (two surgeons) applies a of 63%. When both CT0017 Modifier Rules Page 1 of 21
modifier 78 and 62 are reported on a single procedure, ClaimsXten will multiply 70% x 63% for a new amount of 44.1%. Because the new amount contains a decimal place, the new amount will be rounded up to 45% and applied to the MAA. Coding In addition to modifier to procedure code validation, the following modifiers are used in the adjudication of a claim and may impact reimbursement. 22 Unusual Procedural Services 120% (if approved) See 24 Unrelated Evaluation and Management Service by the Same Physician During a Post-Operative Period* Health Plan s Global Surgery Reimbursement Policy. 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service* No impact on Procedure codes reported with modifier 22 without operative notes/office notes will be reimbursed based on the MAA for the procedure code without review for additional reimbursement. Procedure codes reported with a modifier 22 along with operative notes/office notes will be reviewed to determine if additional reimbursement is warranted. When appended to an E/M procedure code, modifier 24 may override a surgical aftercare edit and the reported E/M code may be eligible for reimbursement. When appended to an E/M procedure code, modifier 25 may override the following edits and the reported E/M code may be eligible for reimbursement: Health Plan s Global Surgery and Evaluation and Management Same Day medical visit with a procedure or service. A problem oriented E/M code CT0017 Modifier Rules Page 2 of 21
Services and Related Modifiers -25 & -57 Reimbursement Policies. reported on the same day as a preventive E/M code by the same provider and modifier 25 is appended to either the problem oriented or preventive E/M code; when both codes are eligible for separate reimbursement, then the MAA for the problem oriented E/M will be reduced by 50%. 26 Professional Component Reimbursement is based on the professional component of a procedure that has both a technical and professional component. 33 Preventive Service No impact on When the primary purpose of the service rendered was the delivery of a preventive service as identified by Health Care Reform legislation, then modifier 33 may be appended to the procedure code. This service is eligible for reimbursement according to the member s preventive services benefit. 50 Bilateral Procedures* Health Plan s Multiple and Bilateral Surgery Processing and Multiple Diagnostic Imaging Reimbursement Policies. This modifier is not appended to codes that are specifically defined as preventive. 150% Bilateral surgical services are subject to the multiple surgery reimbursement rules. The surgical CPT code is required to be reported on one line with modifier 50 appended. Reimbursement is made at the rate of 100% for the first side and 50% for the second side (100 +50 =150%). Due to our claims system's frequency editing logic, CT0017 Modifier Rules Page 3 of 21
Do not report bilateral nonsurgical codes including DME items and diagnostic services, such as radiology, on one line using modifier 50. DO report the applicable code on two lines with the RT or LT modifier appended to each line item. When modifier 50 is reported with a procedure that includes bilateral or unilateral or bilateral in the description, the procedure will not be eligible for reimbursement. 52 Reduced Services 50% Procedure codes reported with modifier 52 are processed and reimbursed at 50% of the MAA. 53 Discontinued Procedure 50% Procedure codes reported with modifier 53 are processed and reimbursed at 50% of the MAA. 54 Surgical Care Only* Health Plan s Global Surgery Reimbursement Policy. 70% Surgical procedures reported with modifier 54 are reimbursed at 70% of the MAA. Reimbursement is made for the surgical procedure only. This lower % rate carves out the pre-op and post op care which is usually included in the global surgical reimbursement for a surgical procedure. This modifier is reported with the surgical code when one provider performs the surgical procedure and another provides the preoperative and/or CT0017 Modifier Rules Page 4 of 21
postoperative care. 55 Post-Operative Management Only* Health Plan s Global Surgery Reimbursement Policy. 56 Preoperative Management Only* Health Plan s Global Surgery Reimbursement Policy. 57 Decision For Surgery* *See also the Health Plan s Global 20% Surgical procedures reported with modifier 55 are reimbursed at 20% of the MAA. This lower % rate carves out the preoperative visit and the surgery which are usually included in the global reimbursement for a surgical procedure. This modifier is reported with the surgical code when one provider performed the postoperative care and another performed the surgical procedure. Procedures with zero postoperative care days reported with modifier 55 will not be eligible for reimbursement. 10% Surgical procedures reported with modifier 56 are reimbursed at 10% of the MAA. This lower % rate carves out the surgery and post-operative care which are usually included in the global reimbursement for a surgical procedure. This modifier is reported with the surgical code when one provider performed the preoperative care and another performed the surgery. No impact on When the decision for surgery is made one day prior to or on the day of a major surgical procedure and CT0017 Modifier Rules Page 5 of 21
Surgery, Evaluation and Management Services and Related Modifiers -25 & -57, Claim Editing Overview, and Documentation and Reporting Guidelines for Evaluation and Management Services Reimbursement Policies 59 Distinct Procedural Service* Health Plan s Bundled Services and Supplies, Frequency Editing, and Modifier 59 Reimbursement Policies. No impact on modifier 57 is appended to a reported E/M code, the modifier will override the one-day prior or the same day pre-op medical visit edit for the major surgical procedure ( 90 day global period) and the reported E/M code may be eligible for reimbursement Modifier 59 will, in many cases, affect the adjudication of the reported code by overriding incidental, mutually exclusive, and rebundle edits, allowing the reported procedure code to be eligible for separate reimbursement. 62 Two Surgeons/Co Surgery* Health Plan s Co-Surgeon/Team Surgeon Services Reimbursement Policy. This modifier will not: o override an edit for a service listed as always bundled in Section 1 of the Bundled Services and Supplies Reimbursement Policy o override an edit for a code listed in the Exceptions to Modifier 59 Override section of the Modifier 59 Reimbursement Policy o override a duplicate procedure edit o override frequency edit limits 63% per surgeon When two surgeons act as cosurgeons, each surgeon will receive 63% of the MAA for an individual code. This lower reimbursement rate reflects the shared responsibility for global surgical services. CT0017 Modifier Rules Page 6 of 21
63 Procedure performed on infants less than 4kg 66 Surgical Team No impact on 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional 78 Unplanned Return to the Operating / Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure 120% Procedures reported with modifier 63 are eligible for additional reimbursement except for: No impact on No impact on those services noted in the modifier 63 description that should not be appended with modifier 63 (for example E/M services or radiology) those services otherwise designated by CPT as not eligible to be appended with modifier 63 CPT codes listed in Appendix F of the CPT manual This modifier has no effect on the MAA of the reported surgical code, but is important to establish team surgery status in the performance of the procedure. When appended to a procedure code, modifier 76 indicates that the repeated procedure/service is not a duplicate. A claim may be reviewed to determine the eligibility for separate reimbursement for the repeated procedure code. When appended to a procedure code, modifier 77 indicates that the repeated procedure/service is not a duplicate. A claim may be reviewed to determine the eligibility for separate reimbursement for the repeated procedure code. 70% Surgical procedures reported with this modifier are reimbursed at 70% of the MAA. CT0017 Modifier Rules Page 7 of 21
During the Postoperative Period* Health Plan s Global Surgery Reimbursement Policy. 79 Unrelated Procedure or Service by the Same Physician During the Post-Operative Period 80 Assistant Surgeon* Health Plan s Assistant Surgeon Services Reimbursement Policy. 81 Minimum Assistant Surgeon* Health Plan s Assistant Surgeon Services Reimbursement Policy. 82 Assistant Surgeon (When Qualified Resident Surgeon Not Available)* Health Plan s Assistant Surgeon Services Reimbursement Policy. 91 Repeat Clinical Diagnostic Laboratory Test* *For more information, refer to the Health Plan s Frequency Editing No impact on This lower % rate carves out the pre-op and post op- care which is usually included in the global surgical reimbursement for a surgical procedure. When appended to a procedure or service, modifier 79 will override global surgical editing and the reported procedure code will be eligible for reimbursement. 16% Surgical procedures reported with modifier 80 are reimbursed at 16% of the total MAA for the reported code. CT0017 Modifier Rules Page 8 of 21 Modifier 80 should not be used to report assistant surgeon services rendered by nonphysician providers 16% Surgical procedures reported with modifier 81 are reimbursed at 16% of the total MAA for the reported code. Modifier 81 should not be used to report minimum assistant surgeon services rendered by non-physician providers. 16% Surgical procedures reported with modifier 82 are reimbursed at 16% of the total MAA for the reported code. No impact on Modifier 82 should not be used to report assistant surgeon services rendered by nonphysician providers. When modifier 91 is appended to a reported laboratory procedure code, our claims editing system will override a frequency edit and allow
and Laboratory & Venipuncture Services Reimbursement Policies separate reimbursement for the repeat clinical diagnostic laboratory test except as described in our Frequency Editing Reimbursement Policy. Modifier 91 will not override component code editing for laboratory organ or diseaseoriented panels. 92 Alternative Laboratory Platform Testing* *See also our Laboratory and Venipuncture Services Reimbursement Policy See comments. Will deny any laboratory codes other than 86701-86703 and 87389 95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system (*See the Health Plan s Telehealth Reimbursement Policy) See comments. Modifier 95 is to be used with CPT codes identified in Appendix P of the CPT codebook. Services reported with modifier 95 will be processed according to the Health Plan s Telehealth reimbursement policy. 99 Multiple Modifiers Procedure reported with modifier 99 will be reviewed with all submitted information. (i.e. Operative notes/office notes) AS Physician Assistant, Registered Nurse First Assistant, Nurse Practitioner or Clinical Nurse Specialist Services for Assistant at Surgery* Health Plan s Assistant Surgeon Services Reimbursement Policy. 16% Surgical procedures reported with modifier AS are reimbursed at 16% of the total MAA for the reported code. Modifier AS is to be used for reporting assistant-at-surgery services by non-physician providers. CT0017 Modifier Rules Page 9 of 21
BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item *See the Health Plan s Durable Medical Equipment Reimbursement Policy See comments This modifier is used when the provider has discussed the purchase/rent option with the patient and the patient has chosen to purchase the DME item. BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item *See the Health Plan s Durable Medical Equipment Reimbursement Policy See comments This modifier is used when the provider has discussed the purchase/rent option with the patient and the patient has chosen to rent the DME item. CC Procedure Code Change No impact on CT Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (nema) xr-29-2013 standard See comments E1-E4 Eyelids No impact on See Health Plan s instructions for information regarding corrected claims submission. Computed tomography services that are furnished on non-nema Standard XR-29-2013-compliant CT equipment must include modifier CT For July December 2016, the allowance for the technical component of diagnostic computed tomography services reported with modifier CT will be reduced by 5% For calendar year 2017 and subsequent years, the allowance for the technical component of diagnostic computed tomography services reported with modifier CT will be reduced by 15% These site-specific modifiers are recognized by ClaimsXten, and may override applicable edits. CT0017 Modifier Rules Page 10 of 21
EX Expatriate beneficiary See comments *See the Health Plan s Durable Medical Equipment Reimbursement Policy This modifier is used when certain durable medical equipment is eligible for reimbursement for those Medicare beneficiaries with permanent addresses outside of the United States for whom items were furnished while the beneficiary was in the United States. F1-FA Hand, Digit No impact on GQ GT KC KI Via asynchronous telecommunications system* Health Plan s Telehealth Reimbursement Policy Via Interactive Audio and Video Telecommunication Systems* Health Plan s Telehealth Reimbursement Policy Replacement of special power wheelchair interface* Health Plan s Health Plan s Durable Medical Equipment Policy. DMEPOS item, 2nd or 3rd month rental* *See the Health Plan s Durable Medical Equipment and Place of Service Reimbursement Policies These site-specific modifiers are recognized by ClaimsXten, and may override applicable edits. Services reported with modifier GQ will be processed according to the Health Plan s reimbursement policy for Telehealth. Services reported with modifier GT will be processed according to the Health Plan s reimbursement policy for Telehealth. Modifier KC is required for replacement of special power wheelchair interface to be eligible for reimbursement. See comments Orthotics and prosthetics classified as purchase only items will not be eligible for reimbursement when reported with rental modifiers. DME items (e.g., E0100- E9999 and K0001- K0902) reported with rental modifier KI with place of service office (11) or urgent care facility (20) CT0017 Modifier Rules Page 11 of 21
will not be eligible for reimbursement. KR Rental item, billing for partial month* *See the Health Plan s Durable Medical Equipment and Place of Service Reimbursement Policies See comments Orthotics and prosthetics classified as purchase only items will not be eligible for reimbursement when reported with rental modifiers. DME items (e.g., E0100- E9999 and K0001- K0902) reported with rental modifier KR with place of service office (11) or urgent care facility (20) will not be eligible for reimbursement. LC Left Circumflex Coronary Artery No impact on LD Left Anterior Descending Coronary Artery No impact on This site-specific modifier is recognized by ClaimsXten, and may override applicable edits. This site-specific modifier is recognized by ClaimsXten, and may override applicable edits. LL Lease/Rental (Used when DME equipment rental is to be applied against the purchase price)* *See the Health Plan s Durable Medical Equipment and Place of Service Reimbursement Policies See comments Monthly rental is equivalent to 1/10 th of the MAA for a DME purchase. Orthotics and prosthetics classified as purchase only items will not be eligible for reimbursement when reported with rental modifiers. DME items (e.g., E0100- E9999 and K0001- K0902) reported with rental modifier LL with place of service office (11) or urgent care facility (20) will not be eligible for reimbursement. CT0017 Modifier Rules Page 12 of 21
LM Left Main Coronary Artery No impact on LT Left Side No impact on This site-specific modifier is recognized by ClaimsXten, and may override applicable edits. This site-specific modifier is recognized by ClaimsXten, and may override applicable edits. MS NR Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty* Health Plan s Durable Medical Equipment (DME) Reimbursement Policy. New when rented (use the NR modifier when DME which was new at the time of rental is subsequently purchased)* Due to our claims system s frequency editing logic: Do not report bilateral nonsurgical codes including DME items and diagnostic services, such as radiology on one line using modifier 50. DO report the applicable code on two lines with the RT or LT modifier appended to each line item. When modifier LT is reported with a procedure that includes bilateral or unilateral or bilateral in the description, the procedure will not be eligible for reimbursement. A DME item that is eligible for maintenance reimbursement will be reimbursed no more than two times per year at a frequency of at least 179 days apart. A DME item that is not eligible for maintenance reimbursement will be denied. Modifier NR is required for an item to be eligible for reimbursement as a purchase when the item was originally rented as a new item. Certain rent-to-purchase DME CT0017 Modifier Rules Page 13 of 21
Health Plan s Durable Medical Equipment Reimbursement Policy. items (e. g., E0601 (CPAP/APAP); E0470, E0471 (BPAP); E0561, E0562 (humidifiers)), are not routinely purchased up-front and must be reported with the appropriate DME rental modifier; these rent to purchase items will not be eligible for reimbursement when reported with purchase modifier NR. NU New equipment purchase* Health Plan s Durable Medical Equipment Reimbursement Policy. Modifier NU is required for item to be eligible for reimbursement of purchase. Certain rent-to-purchase DME items (e. g., E0601 (CPAP/APAP); E0470, E0471 (BPAP); E0561, E0562 (humidifiers)), are not routinely purchased up-front and must be reported with the appropriate DME rental modifier; these rent to purchase items will not be eligible for reimbursement when reported with purchase modifier NU. P3, P4, P5 PA PB PC Anesthesia Physical Status Modifiers* Health Plan s Anesthesia Reimbursement Policy. Surgery or other invasive procedure on wrong body part Surgery or other invasive procedure on wrong patient Wrong surgery or other invasive procedure on patient Anesthesia codes reported with modifier P3, P4, or P5 are eligible for additional unit reimbursement: P3-1 unit (15 minutes) P4-2 units (30 minutes) P5-3 units (45 minutes) Procedures reported with modifier PA will be denied. Procedures reported with modifier PB will be denied. Procedures reported with modifier PC will be denied CT0017 Modifier Rules Page 14 of 21
PT Colorectal cancer screening test; converted to diagnostic test or other procedure When a service identified by Health Care Reform legislation as a colorectal cancer screening test is initiated as a screening, but becomes a diagnostic service, modifier PT may be appended to the procedure code. RA Replacement of a DME, Orthotic, or Prosthetic Item* Health Plan s Durable Medical Equipment Reimbursement Policy. This service is eligible for reimbursement according to the member s preventive services benefit. Replacement of approved medically necessary member owned DME equipment may be eligible for reimbursement except when replacement is due to damage, neglect, misuse, or mistreatment of the equipment by the member Replacement of Health Plandefined frequently serviced DME items will be denied. Health Plan requires frequently serviced DME items to be rented, and repair and/or replacement of these items is included in the rental fee. RB Replacement of a Part of a DME, Orthotic, or Prosthetic Item Furnished as Part of a Repair* Health Plan s Durable Medical Equipment Reimbursement Policy. Reasonable and necessary repairs or replacement part of approved medically necessary member-owned equipment may be eligible for reimbursement except when the cost of repairs and/or replacement part(s) will exceed the MAA for the purchase of member-owned equipment or CT0017 Modifier Rules Page 15 of 21
when the required repairs are due to damage, neglect, misuse or mistreatment of the equipment by the member. Replacement of parts of Health Plan-defined frequently serviced DME items will be denied. Health Plan requires frequently serviced DME items to be rented, and repair and/or replacement of these items is included in the rental fee. RC Right Coronary Artery No impact on RI RR Ramus Intermedius Coronary Artery Rental Health Plan s Durable Medical Equipment Reimbursement Policy. No impact on This site-specific modifier is recognized by ClaimsXten, and may override applicable edits. This site-specific modifier is recognized by ClaimsXten and may override applicable edits. Modifier RR is used to determine the MAA based on provider's contractual arrangement and/or member's benefit. Orthotics and prosthetics classified as purchase only items will not be eligible for reimbursement when reported with rental modifiers. DME items (e.g., E0100- E9999 and K0001- K0902) reported with rental modifier RR with place of service office (11) or urgent care facility (20) will not be eligible for reimbursement. CT0017 Modifier Rules Page 16 of 21
RT Right Side No impact on This site-specific modifier is recognized by ClaimsXten, and may override applicable edits Due to our claims system s frequency editing logic: Do not report bilateral nonsurgical codes including DME items and diagnostic services, such as radiology on one line using modifier 50. DO report the applicable code on two lines with the RT or LT modifier appended to each line item. When modifier RT is reported with a procedure that includes bilateral or unilateral or bilateral in the description, the procedure will not be eligible for reimbursement. SA SG SU Nurse practitioner rendering service in collaboration with a physician Ambulatory surgical center (ASC) facility service Procedure performed in physician s office (to denote use of facility and equipment). T1-TA Left/Right Foot, Digit No impact on Surgical services and procedures reported with modifier SA will not be eligible for reimbursement. Procedures reported with modifier SG will not be eligible for reimbursement Procedures reported with modifier SU will not be eligible for separate reimbursement. Use of an office facility and equipment are included in the practice expense of the Relative Value Unit (RVU) for a rendered service or procedure. These site-specific modifiers are recognized by ClaimsXten, and may override applicable edits. CT0017 Modifier Rules Page 17 of 21
TC Technical Component Reimbursement is based on the technical component of a procedure that has both a technical and professional component. UE Used durable medical equipment purchase* Health Plan s Durable Medical Equipment Reimbursement Policy. Modifier UE is required for item to be eligible for reimbursement of purchase. Certain rent-to-purchase DME items (e. g., E0601 (CPAP/APAP); E0470, E0471 (BPAP); E0561, E0562 (humidifiers)), are not routinely purchased up-front and must be reported with the appropriate DME rental modifier; these rent to purchase items will not be eligible for reimbursement when reported with purchase modifier UE. XE Separate Encounter: A service that is distinct because it occurred during a separate encounter * See also the Health Plan s Bundled Services and Supplies, and Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU Reimbursement Policies. Services billed with modifier XE will be processed in accordance with the Health Plan s reimbursement policy for Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU XP Separate Practitioner: a service that is distinct because it was performed by a different practitioner * See also the Health Plan s Bundled Services and Supplies, and Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU Reimbursement Policies. Services billed with modifier XP will be processed in accordance with the Health Plan s reimbursement policy for Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU CT0017 Modifier Rules Page 18 of 21
XS Separate Structure: A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure * See also the Health Plan s Bundled Services and Supplies, and Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU Reimbursement Policies. Services billed with modifier XS will be processed in accordance with the Health Plan s reimbursement policy for Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service * See also the Health Plan s Bundled Services and Supplies, and Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU Reimbursement Policies. Services billed with modifier XU will be processed in accordance with the Health Plan s reimbursement policy for Modifiers 59 (Distinct Procedural Service) and XE, XP, XS, & XU The following table lists some (but not all) commonly reported modifiers that the Health Plan considers Informational only. These modifiers have no effect on the maximum allowable amount of the reported code. Modifier Description 23 Unusual Anesthesia Informational only with no additional compensation. This modifier has no effect on the reimbursement of the reported anesthesia code. The provider should append the appropriate physical status modifier P1-P6 to indicate a specific physical condition. 32 Mandated Services Informational only. Modifier 32 has no effect on the MAA for the reported procedure code CT0017 Modifier Rules Page 19 of 21
Modifier Description 47 Anesthesia by Surgeon Informational only with no additional compensation. Modifier 47 has no effect on the MAA for the reported procedure code. 51 Multiple Procedures Informational only. Modifier 51 has no effect on the MAA for the reported procedure code. The Health Plan determines the ranking for applying multiple surgery reimbursement rules through its claim processing system not through the use of 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period this modifier. Informational only. 90 Reference (Outside) Laboratory Informational only 92 Alternative Laboratory Platform Informational only Testing AA Anesthesia Services Performed Personally by Anesthesiologist Informational only. This modifier has no effect on the reimbursement for the reported anesthesia code. P1, P2, P6 Anesthesia Physical Status Modifiers* Q5 Q6 *For more information, see also the Health Plan s Anesthesia Reimbursement Policy. Service furnished under a reciprocal billing arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area Service furnished under a fee-fortime compensation arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a Informational only. Anesthesia codes reported with modifier P1, P2, or P6 are not eligible for additional unit reimbursement. Informational only. Informational only. CT0017 Modifier Rules Page 20 of 21
Modifier Description rural area CPT is a registered trademark of the American Medical Association ClaimsXten is a registered trademark of McKesson Information Solutions LLC Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member s benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Anthem Blue Cross and Blue Shield. 2017 Anthem Blue Cross and Blue Shield CT0017 Modifier Rules Page 21 of 21