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Medicare Part B Informational Only Modifiers Cheat Sheet (DRAFT) by [deleted]

Medicare Part B Informational Modifiers

This is a draft cheat sheet. It is a work in progress and is not finished yet.


For Medicare purposes, modifiers are two-digit codes that may consist of alpha and/or numeric charac­ters, which may be appended to procedure codes and/or HCPCS codes, to provide additional inform­ation needed to process a claim. This includes both HCPCS Level 1 (CPT) and HCPCS Level II codes. Modifiers answer the questions such as, which one, how many, what kind, and when?

A two-digit code appended to procedure codes
May affect reimbu­rsement
May be inform­ational only
Updated annually

What is the purpose of a Modifi­er?
Used on a Medicare Claim to provide additional inform­ation for the code that is being billed and, if approved, may determine the payment for the code.

Payment Modifier vs Inform­ational Modifier

The CPT coding system includes 2-digit modifier codes used to report that a service or procedure has been altered or modified by some specific circum­stance without altering or modifying the basic definition for the CPT code. Proper use speeds up claim proces­sing, while improper use can result in claim delays, reject­ions, or denials.

Info­rma­tional Modifi­ers are Used for "­inf­orm­ati­ona­l" purposes only, and do not affect reimbu­rse­ment, while Pricing or Payment Modifi­ers, always affect reimbu­rse­ment. Unders­tanding which modifiers affect reimbu­rsement and which ones do not is critical to properly submit a claim when more than one modifier is needed to describe a single CPT code.

The Multi-­Carrier System (MCS), used for claims proces­sing, requires placement of pricin­g/p­ayment modifiers in the first modifier position. Some pricin­g/p­ayment modifiers are not limited to the first position. In such cases, if there is another pricing modifier submitted that is required to be in the first modifier field, these modifiers should be in the second, third or fourth modifier position.

When more than four modifiers apply, enter modifier 99 in the first modifier field. In the narrative field (item 19 on the claim form), list all modifiers in the correct ranking order, making sure to identify which detail line or procedure code to which the modifiers apply

Inform­ational Modifiers

AQ Services provided in a Health Profes­sional Shortage Area (HPSA)
CB Services ordered by a dialysis facility physician as part of the ESRD benefi­ciary's dialysis benefit, is not part of the composite rate, and is separately reimbu­rsable
CR Emergency health care needs of benefi­ciaries and providers affected by Hurricane Katrina and any future disasters
GA The provider or supplier has provided an Advance Benefi­ciary Notice of Noncov­erage (ABN) to the patient and has a signed copy on file
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
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 Statut­orily excluded service - If the service provided is statut­orily excluded from the Medicare Program, the claim will deny whether or not the modifier is present on the claim
GZ The provider or supplier expects a medical necessity denial; however, did not provide an Advance Benefi­ciary Notice of Noncov­erage (ABN) to the patient
Q5 Service furnished by a substitute physician under a reciprocal billing arrang­ement
Q6 Service furnished by a locum tenens physician
22 Increased Procedural Service requiring work substa­ntially greater than typically required
24 Unrelated evaluation and management (E/M) service by the same physician* during a postop­erative period
25 Signif­icant, separately identi­fiable evaluation and management (E/M) service by the same physician* on the day of a procedure
27 Multiple Outpatient Hospital E/M Encounters on the Same Day (Not required by CMS and not to be used by physicians for reporting of multiple E/M services)
52 Reduced Service reports a partially reduced or eliminated service or procedure
57 Indicates an Evaluation and Management (E/M) service resulted in the initial decision to perform surgery either the day before a major surgery (90-day global) or the day of a major surgery
58 Indicates a staged or related procedure or service by the same physician* during the postop­erative period
59 Distinct Procedural Service identifies proced­ure­s/s­ervices not normally reported together, but approp­riately billable under the circum­stances
63 Procedure Performed on Infants less than 4 kg
66 If a team of surgeons (more than two surgeons of different specia­lties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier "­-66­"
74 Discon­tinued Out-Pa­tient Hospit­al/­Amb­ulatory Surgery Center (ASC) Procedure after admini­str­ation of anesthesia
76 Repeat Procedure by the Same Physician; use when it is necessary to report repeat procedures performed on the same day
77 Repeat Procedure by another physician
79 Unrelated procedure by the same physician during the postop­erative period
90 Reference (Outside) Laboratory
99 Multiple Modifiers are required on one line of service
Modifier 99 has specific instru­ctions on its own separate fact sheet.