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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.3 Coding : 6.3.5 Modifiers

6.3.5
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.
 
All eligible organizations and covered entities that are enrolled in the federal 340B Drug Pricing Program to purchase 340B discounted drugs must use modifier U8 when submitting claims for 340B clinician-administered drugs.
Non-compliance with this new requirement to use modifier U8 on all claims submitted for 340B clinician-administered drugs may jeopardize a covered entity’s 340B status with the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA).
Providers can refer to the HRSA website at www.hrsa.gov/opa/index.html for more information about the 340B Drug Pricing Program.
Use for physician reporting of a discontinued procedure. For outpatient/ASC reporting of a discontinued procedure, see modifier 73 and 74.
Providers who perform the preoperative care only must bill the surgical code with modifier 56 and is reimbursed 10 percent of the global fee.
80 and KX+
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.
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.
Injectable medication is the accepted treatment of choice. Oral medication regimens have proven ineffective or are not available.
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.
Use with external causes of injury and poisoning (E Codes) procedures and morphology of neoplasms (M Codes) procedures to specify antepartum or postpartum care.
Use to describe circumstances in which an office visit was provided at the same time as other separately identifiable services. Refer to the CMS NCCI website for additional information.
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.
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.
Use to indicate that the services were performed by an advanced practice registered nurse (APRN) or CNM rendering services in collaboration with a physician.
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.
Code to indicate the procedure or service was independent from other services performed on the same day. Refer to the CMS NCCI website for additional information.
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.
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
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
* Description is defined by the state.
 
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.

Texas Medicaid & Healthcare Partnership
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