TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Coding > Modifiers

   
 

6.3.5 Modifiers

Modifiers describe and qualify the services provided by Texas Medicaid. A modifier is placed after the five-digit procedure code. Up to two modifiers may apply per service. Examples of frequently used modifiers are listed in the following table. Refer to the service-specific sections for additional modifier requirements.

Modifier
Special Instructions/Notes (if applicable)

Ambulance

ET

Use for emergency services.

GY

Use to indicate that no medical necessity existed for a transport.

Surgeons

53

Use for physician reporting of a discontinued procedure. For outpatient/ASC reporting of a discontinued procedure, see modifier 73 and 74.

54+

Surgeons who do not provide the postoperative care for a patient must bill the surgery code with modifier 54. The modifier will reimburse the surgeon at 80 percent of the allowed amount.

55+

Physicians who provide only the postoperative care may bill the appropriate visit codes and must use modifier 55 to indicate only postoperative care services were provided. Services indicated as postoperative care only by use of this modifier will not be denied as part of the global surgical fee.

62+

Cosurgery. Two surgeons perform the specific procedure(s).

66+

Cosurgery. Two surgeons are necessary to perform the highly complex surgical procedure(s).

76+

Use modifier 76 or 77 for transplant procedures if it is a second transplant of the same organ.

77+

Use modifier 76 or 77 for transplant procedures if it is a second transplant of the same organ.

Assistant Surgeons

80 and KX+

Use modifier 80 and KX together to indicate an assistant surgeon in a teaching facility:

In a case involving exceptional medical circumstances such as emergency or life-threatening situations requiring immediate attention.

When the primary surgeon has a policy of never, without exception, involving a resident in the preoperative, operative, or postoperative care of one of his or her patients.

In a case involving a complex surgical procedure that qualifies for more than one physician.

AS

Use when the physician assistant is not enrolled as an individual provider and provides assistance at surgery.

Sterilizations

PM

Use to indicate post-menopausal.

PS

Use to indicate previously sterilized.

Excision of Lesions/Masses

KX+

Use modifier KX if the excision/destruction is due to one of the following signs or symptoms: inflamed, infected, bleeding, irritated, growing, limiting motion or function. Use of this modifier is subject to retrospective review.

Injections

AT

Use to indicate acute conditions.

JA

Administered intravenously.

JB

Administered subcutaneously.

KX+

Use modifier KX to indicate the injection was due to:

Oral route contraindicated or an acceptable oral equivalent is not available.

Injectable medication is the accepted treatment of choice. Oral medication regimens have proven ineffective or are not available.

Patient has a temperature over 102 degrees (documented on the claim) and a high level of antibiotic is needed quickly.

Injection is medically necessary into joints, bursae, tendon sheaths, or trigger points to treat an acute condition or the acute flare up of a chronic condition.

Visits

52+

Use with normal newborn care if the service did not comprise a THSteps screen.

76+

Use to indicate the repeated non-clinical procedure.

FP+

Use to indicate that the service was part of an annual family planning examination.

TH+

Use with evaluation and management procedures to specify antepartum or postpartum care.

25

Use to describe circumstances in which an office visit was provided at the same time as other separately identifiable services.

Anesthesia

One of the following modifiers must be used by physicians in conjunction with the CPT code for anesthesia services:

AA

Use to indicate that the services were performed personally by the anesthesiologist.

AD

Use to indicate medical supervision by a physician or more than four concurrent anesthesia procedures.

Modifier is also used when a modifier is not submitted on the claim.

QK

Use to indicate medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.

FQHC and RHC

Services provided by a health-care professional require one of the following modifiers:

AH

Use to indicate that the services were performed by a clinical psychologist.

AJ

Use to indicate that the services were performed by a clinical social worker.

AM

Use to indicate that the services were performed by a physician or team member service (includes clinical psychiatrist).

SA

Use to indicate that the services were performed by an advanced practice nurse (APN) or CNM rendering services in collaboration with a physician.

TD

For home services performed by a RN and provided in areas with a shortage of home health agencies.

TE

For home services performed by an LVN and provided in areas with a shortage of home health agencies.

U1

Licensed professional counselor

U2

Licensed marriage and family therapist

U7*

Physician assistant services for other than assistant at surgery

The following modifiers may be used in addition to the modifier identifying the health-care professional that rendered the service:

EP

Use to indicate THSteps services (FQHC only).

FP

Use to indicate that the service was part of an annual family planning examination.

TH

Use to indicate the encounter is for antepartum care or postpartum care.

TU

For services provided outside of normal business hours to a client enrolled in the PCCM program.

U5*

State-defined modifier for use with case management services.

Certified Registered Nurse Anesthetist (CRNA)

One of the following modifiers must be used by CRNAs in conjunction with the CPT code for anesthesia services:

QX

Use to indicate the anesthesia was medically directed by the anesthesiologist.

QZ

Use to indicate the anesthesia was directed by the surgeon.

Abortion

G7

Use by performing physicians, facilities, anesthesiologists, and CRNAs (with appropriate procedure code) when requesting reimbursement for abortion procedures that are within the scope of the rules and regulations of Texas Medicaid.

Vision

RB

Use modifier RB to indicate repair or replacement lenses or frames

VP+

Use when billing for an adult with diagnosis code 37931.

Laboratory/Radiology

26+

Use for laboratory interpretations and radiological procedures.

91+

Use for repeat laboratory clinical test.

76

Use for repeat laboratory nonclinical test.

SU+

Indicates necessary equipment is in physician's office for RAST/MAST testing or Pap smears.

TC+

The modifier TC is used for technical radiological procedures.

Q4+

Use for lab/radiology/ultrasound interps by other than the attending physician.

Therapy

AT+

Must be used to indicate the necessity of an acute condition for occupational therapy (OT), physical therapy (PT), osteopathic manipulation treatment (OMT), or chiropractic services.

GN

Use to indicate outpatient speech language pathology.

GO

Use to indicate outpatient occupational therapy.

GP

Use to indicate outpatient PT.

U4*

Reassessment

THSteps Medical

AM

Physician, team member service

EP

FQHCs must use modifier EP for services provided under THSteps.

SA

Nurse practitioner rendering service in collaboration with a physician

U7*

Physician assistant services for other than assistant at surgery

TD

Registered nurse

SC

Medically necessary service or supply

23

Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier 23 to the procedure code of the basic service or by use of the separate five-digit modifier code 09923

32

Mandated Services: Services related to mandated consultation or related services (e.g., peer review organization [PRO], third party payer, governmental, legislative or regulatory requirement) may be identified by adding the modifier 32 to the basic procedure or the service may be reported by use of the five digit modifier 09932

Physicians

Q5

Informal reciprocal arrangement (period not to exceed 14 continuous days)

Q6

Locum tenens or temporary arrangement (up to 90 days)

Radiologists

U6

CT, CTA, MRI, and MRA studies provided in the emergency department

Durable Medical Equipment

NU

Use to indicate purchased equipment.

RR

Use to indicate leased equipment.

Telemedicine

GT

Use with appropriate evaluation and management code.

AM

Use with RHC and FQHC encounter codes.

SA

Use with RHC and FQHC encounter codes.

+ Modifier is required for accurate claims processing.
* Description is defined by the state.

Other Common Modifiers

AE

AF

AG

AK

AR

CB

CD

CE

CF

CG

KC

KD

KF

LT

M2

RD

RT

SW

SY

TL*

UN

UP

UQ

UR

US

* Must be used by providers rendering Early Childhood Intervention (ECI)-THSteps/CCP therapy and nutritional services.

The following modifiers may appear on R&S Reports (they are not entered by the provider):

PT. The DRG payment was calculated on a per diem basis for an inpatient stay because of patient transfer.

PS. The DRG payment was calculated on a per diem basis because the patient exhausted the 30-day inpatient benefit limitation during the stay.

PE. The DRG payment was calculated on a per diem basis because the patient was ineligible for Medicaid during part of the stay. Also used to adjudicate claims with adjustments to outlier payments.

Note: Modifiers PT, PS, and PE will appear for DRG claims only.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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