Ambulance

ET

Use for all emergency transport 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+

Surgeon who performs the surgical procedure only must bill the surgical code with modifier 54 and is reimbursed 70% of the global fee.

55+

Provider who performs the postoperative care only must bill the surgical code with modifier 55 and is reimbursed 20% of the global fee.

56+

Providers who perform the preoperative care only must bill the surgical code with modifier 56 and is reimbursed 10 percent of the global fee.

58+

Staged or related procedure or services by the same physician during the postoperative period.

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.

78+

Return to the operating room for a related procedure during the postoperative period.

79+

Unrelated procedure or service by the same physician during the postoperative period.

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 external causes of injury and poisoning (E Codes) procedures and morphology of neoplasms (M Codes) 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 modifier combinations must be used by anesthesiologists directing non-CRNA qualified professionals.

AA and U1

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

AD and U1 (Emergency circumstances only)

Use when directing five or more concurrent procedures provided by non-CRNA qualified professionals. Used in emergency circumstances only and limited to 6 units (90 minutes) per case for each occurrent requiring five or more concurrent procedures.

QK an U1

Use when directing two, three, or four concurrent procedures provided by non-CRNA qualified professionals.

QY and U1

Use when directing one procedure provided by a non-CRNA qualified professional.

One of the following modifier combinations must be used by anesthesiologists directing CRNAs.

AD and U2 (Emergency circumstances only)

Use when directing five or more concurrent procedures involving CRNA (s). Used in emergency circumstances only and limited to 6 units (90 minutes) per case for each occurrence requiring five or more concurrent procedures.

QK and U2

Use when directing two, three, or four concurrent procedures involving CRNAs.

QY and U2

Use when directing one procedure by a CRNA.

One of the following modifier combinations must be used by CRNAs.

QX and U2

Use to indicate the anesthesia was directed by the surgeon.

QZ and U1

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

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.

TS

Use to indicate a case management follow-up service

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.

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 replacement of prosthetic or nonprosthetic eyeglasses or contact lenses.

VP+

Use when billing prosthetic eyeglasses or contact lenses with a diagnosis of aphakia.

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

U5*

Intermediate oral examination with dental varnish

U7*

Physician assistant services for other than assistant at surgery

TD

Registered nurse

THSteps Exceptions to Periodicity

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)

Radiology Services

U6

CT, CTA, MRI, MRA, Cardiac Nuclear Imaging, and PET Scan studies provided in the emergency department.

Obstetric ultrasounds provided in the emergency department or during a hospital observation stay.

Durable Medical Equipment

NU

Use to indicate purchased equipment.

RR

Use to indicate leased equipment.

Telemedicine

GT

Use with appropriate evaluation and management codes.

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