...WORK IN CURRENT OCCUPATION MM DD YY MM DD YY TO n/a n/a 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 17b. 19. RESERVED FOR LOCAL USE TY Thomas Glassman, M.D 1C NPI 1080808080 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 20. OUTSIDE LAB? $CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. | 2. | 24. A. MM V.08 . . . 3. | 176.9 . . YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # 23. PRIOR AUTHORIZATION # . SI 042 . 4. | . E. DIAGNOSIS POINTER (1, 2, 3, or 4) DATE(S) OF SERVICE From To DD YY MM B. C. DD YY PLACE OF SERVICE EMG D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER F. $ CHARGES G. DAYS OR UNITS H. EPSDT Family Plan I. ID. QUAL. ER 06 01 15 07 07 07 07 11 11 11 11 99214 80050 1 NPI 06 07 2 3 NPI 07 01 80502 NPI UN IV 08 NPI 26. PATIENT’S ACCOUNT # 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) 25. FEDERAL TAX I.D. # SSN EIN 28. TOTAL CHARGE $ 29. AMOUNT PAID $ 5551116679 080811 YES NO 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( SIGNED DATE a. b. a. b. IX STATE D.C ) SEX F . J. PROVIDER ID.......
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Hcr/220 Final Project Cms Form Part 1
... John Wise M.D. 1C NPI 1080808080 N/A 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO EM 20. OUTSIDE LAB? $CHARGES (conditional requirement) 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. | 2. | 24. A. MM V.08 . . . 3. | 176.9 . . YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # N/A . conditional E. DIAGNOSIS POINTER (1, 2, 3, or 4) requirement G. DAYS OR UNITS SI 042 . 23. PRIOR AUTHORIZATION # 4. | . conditional requirement F. $ CHARGES H. EPSDT Family Plan DATE(S) OF SERVICE From To DD YY MM B. C. DD YY PLACE OF SERVICE EMG D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER I. ID. QUAL. UN IV Detailed examination, screening blood panel, pathology services 99214 05 01 11 05 01 11 11 Detailed examination, screening blood panel, pathology services 80050 05 15 11 05 15 11 11 Detailed examination, screening blood panel, pathology services 80502 06 07 11 06 07 11 11 Detailed examination, screening blood panel, pathology services 07 11 11 07 11 11 11 ER 1 N/A N/A N/A N/A 1 1 NPI 2 3 NPI 1 1 $ NPI NPI 29. AMOUNT PAID 25. FEDERAL TAX I.D. # SSN EIN 26. PATIENT’S ACCOUNT # 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) 28. TOTAL CHARGE $ 5551116679 080811 YES NO N/A N/A 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES......
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Hcr 220 Appendix C
...WORK IN CURRENT OCCUPATION MM DD YY MM DD YY TO 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 17b. NPI 1080808080 19. RESERVED FOR LOCAL USE TY John West, M.D. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 05 01 2011 07 20. OUTSIDE LAB? $CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1. | 2. | 24. A. MM 042 . YES NO 22. MEDICADE RESUBMISSION CODE ORIGINAL REF. # 23. PRIOR AUTHORIZATION # . . 3. | . . SI 176.9 . 4. | . . E. DIAGNOSIS POINTER (1, 2, 3, or 4) DATE(S) OF SERVICE From To DD YY MM B. C. DD YY PLACE OF SERVICE EMG D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER F. $ CHARGES G. DAYS OR UNITS H. EPSDT Family Plan I. ID. QUAL. ER 05 01 07 11 11 05 07 15 11 11 11 99205 81400 NPI 06 NPI NPI UN IV NPI 26. PATIENT’S ACCOUNT # 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) 25. FEDERAL TAX I.D. # SSN EIN 28. TOTAL CHARGE $ 29. AMOUNT PAID $ 5551116679 080811 YES NO 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( SIGNED DATE a. b. a. b. IX STATE DC ) SEX F . 11 2011 J. PROVIDER ID. # 1080808080 1080808080 30. BALANCE DUE $ ) ...
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Dangled Missplaced Modifiers
...1. After regaining consciousness, the accident victim was helped out of the car by a passerby. 2. Strolling down South Beach, you’ll see the Park Hotel, one of Art Deco buildings. 3. To qualify for the certificate, students must maintain perfect attendance. (C) 4. Immediately following birth, nurses apply identification tags to all newborns’ wrists. 5. Looking back through history, no presidency has seen greater trial and tribulation. (C) 6. Walking up the driveway, the detectives immediately saw the Rolls Royce and Mercedes parked in the garage. 7. After surviving three days in freezing conditions, the child was miraculously saved by doctors. 8. Plunging 1,000 feet into the gorge, we were amazed at the grandeur of Yosemite Falls. (C) 9. To be most fruitful, tomato plants should be set out in the spring after the soil warms. 10. Reacting to stress, women are more likely to eat food than by men. 11. We can make arrangements that you can live with; with the tax collector. 12. The patient with a severe emotional problem was referred to a psychiatrist. 13. Firefighters rescued a dog from a car that had a broken leg. (C) 14. The sun, with a golden glow, greeted me as I came out of the house. 15. He carried the puppy in his car that was only three weeks old. (C) 16. After leaving the concert and walking to the parking lot, Lisa’s car would not start. 17. Seasoned in a spicy crumb mixture, your Chicken Fingers can be complimented with honey mustard or......
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...HCR/210 Due Date: 11/8/13 Professor: Holt Applying Level II HCPCS Modifiers 1. Portable home oxygen unit: GY. I assigned this code modifier because this is the correct code for an item or service statutorily excluded. A portable oxygen unit an Item statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit. 2. Emergency ambulance transport and extended life support: QM. I assigned this code modifier because an ambulance was provided for the patient to go to the hospital. 3. Diagnostic mammogram, left breast: LT. I assigned this code modifier because the test was done on the left breast. 4. Cortisone 10 mg injection, right shoulder: RT. I assigned this code modifier because the injection was given on the right shoulder of the patient. 5. Nonelectric wheelchair: GY. I assigned this code modifier because a nonelectric wheelchair is an Item statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit. 6. Intravenous catheter line, right arm: RT. I assigned this code modifier because of the operation was done on the right arm of the patient. 7. Laboratory certification, cytology specimens: TC. I assigned this code modifier of the operation because this code is used to represent a technical component. 8. Chest X-ray: TC. I assigned this code modifier because this code is used to represent a......
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...Applying level II HCPCS modifiers Apply the appropriate Level II Healthcare Common Procedure Coding System (HCPCS) code modifier for each of the following examples. Explain your rationale for each selection. Portable home oxygen unit Emergency ambulance transport and extended life support Diagnostic mammogram, left breast Cortisone 10 mg injection, right shoulder Nonelectric wheelchair Intravenous catheter line, right arm Laboratory certification, cytology specimens Chest X-ray Prosthetic hip replacement, left side Electric hospital bed * * Angioplasty of right coronary artery –RC I chose this HCPCS Modifier Code because the procedure was performed on the right coronary artery. RC is the medical term for right Emergency ambulance transport and extended life support provided directly by provider of service –QN I used this because emergency ambulance transport and extended life support was given directly by a provider of services, for example, a volunteer ambulance service. Diagnostic mammogram following screening mammogram, left breast –GG This modifier code was chosen because a mammogram was performed, and using this code described more than using a code for left side. Cortisone 10 mg injection, right shoulder –RT I chose this modifier code because the cortisone 10 mg injection procedure was performed on the right side, or right shoulder of the body. Nonelectric wheelchair- GY I chose this Modifier code because the equipment was......
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Ski Pro Corporation
...vessel 93000 – Electrocardiogram routine ECG with at least 12 weeks with interpretation report 93015 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise continuous electrocardiographic monitoring and/or pharmacological stress with physician’s supervision with interpretation and report. 93024 – Engonovine provocation test 93040 – Rhythm ECG 1-3 leads; with interpretation and report 93278 – Signal averaged electrocardiography (SAECG) 93501 – Right heart catheterization 93505 – Enclomyocardial litopsy 93541 – for pulmonary angiography 93543 – for selective left ventricular or left aerial angiography CPT Modifiers 23 – unusual anesthesia 50 – bilateral procedure 53 – discontinued procedure 57 – decision for surgery 59 – distinct procedural service HCPCS codes A4556 – electrodes A9700 – supply of injectable contrast material for use in echocardiography, per study References: www.cms.hhs.gov www.stronghealth.com www.hsh.k12.nf.ca/bil2201.com www.cardiologchannel.com/cardiologist.shtmlwww.fi.edu/learn/heart/systems.com...
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Job Description Report
...Other responsibilities include modifier assignments and completing various fields on the computerized abstract. The coder works under minimal supervision. This position requires analysis and critical attention to detail. Internal contacts are primarily within the work group, with close collaboration with the Clinical Documentation Improvement Specialist group. External contacts may include physicians, but are limited and infrequent. Minimum Requirements Three (3) years experience hospital coding required Two (2) years experience coding hospital inpatient strongly preferred Education/Licenses/Certifications Associates Degree required (CAHIIM accredited program preferred) Coding certification required: RHIT, RHIA, or CCS *Five years experience in hospital inpatient coding plus a CPC-H Certificate may be substituted for education and experience requirements listed above. Additional Information Preferred certification for hospital coding is RHIT, RHIA, or CCS; all other listed certification will be taken into consideration with application Job description Outpatient Medical Coder Outpatient Medical Coding job involves coding charts for patients who are treated and released within 24 hours (physician offices, one-day surgery etc.). Outpatient Medical Coders use Current Procedural Terminology (CPT) coding system; however, they must also have a working knowledge of NCCI edits, ICD-9-CM Volume 3, ICD-10 (Diagnostic Codes) and HCPCS (Medicaid and Medicare) Level......
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Hcr 220 Week 1 Appendix a Final Project Overview and Timeline
...One of the final project you explain how HIPAA, ICD, CPT, and HCPCS influence medical billing and demonstrate your knowledge of the steps involved in this process from time of patient intake to discharge by completing a CMS 1500 claim form. In Part Two, you examine HIPAA privacy regulations and discuss the social, ethical, and legal ramifications of improper information disclosure. You discuss your findings in a 1,500- to 1,750-word paper. Final Project Timeline You should budget your time wisely and work on your project throughout the course. As outlined below, some assignments in the course are designed to assist you in creating your final project. If you complete your course activities and use the feedback provided by the instructor, you will be on the right track to complete your project successfully. HCR 220 Week 1 Appendix A Final Project Overview and Timeline Get Tutorial by Clicking on the link below or Copy Paste Link in Your Browser https://hwguiders.com/downloads/hcr-220-week-1-appendix-final-project-overview-timeline/ For More Courses and Exams use this form ( http://hwguiders.com/contact-us/ ) Feel Free to Search your Class through Our Product Categories or From Our Search Bar (http://hwguiders.com/ ) Axia College Material Appendix A Final Project Overview and Timeline Final Project Overview In Part One of the final project you explain how HIPAA, ICD, CPT, and HCPCS influence medical billing and demonstrate your knowledge......
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...W-codes (Level III HCPCS codes) for vocational rehabilitation services Table 2 of rule 4123-6-37 lists the covered .2 vocational rehabilitation services. Outlier reconciliation process Grants the Medicare administrative contractors the ability to execute an outlier reconciliation process Will not execute the Medicare outlier reconciliation process Inpatient only services Does not provide payment for services that are designated as inpatient only with payment status indicator C Reimburses managed care organizationapproved inpatient only services at reasonable cost Reasonable cost is calculated as allowed charge * hospital overall outpatient cost-tocharge ratio as indicated in the applicable Medicare outpatient provider specific file. BWC medical policy will release a policy on inpatient only procedures. Hold harmless calculation Executes the hold harmless provision on a quarterly basis with an end of year reconciliation process Executes the hold harmless provision at the bill level Will not execute a reconciliation process Provision applies only to eligible line items identified by the payment status indicator Eligible payment status indicators include G, H, K, P R, S, T, U, V and X. , Integrated outpatient code editor (I/OCE) Uses the I/OCE as published in the applicable quarterly program transmittal Uses the I/OCE but will bypass 10 edits Devices provided at no or partial cost (FB/FC Modifier) provision Reduces the APC payment when hospitals apply modifier FB......
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...94578 PLACE OF SERVICE (Check one – please do not circle): Inpatient Hospital DOB: Outpatient Hospital Facility Provider’s Office Ambulatory Surgical Center Home RENDERING PROVIDER Name/Facility: WE CARE REHAB SERVICE INC. Phone: PHYSICAL THERAPY Specialty/Dept: NPI#: Fax: TIN#: (510)264-4202 (510)264-4192 Address: 27200 CALAROGA AVE City: HAYWARD Anticipated Date of Service: State: CA Zip: 94545 Non-Contracted. Provide reason for out of network provider request. Please do not enter general comments here. DIAGNOSES / SERVICE CODES ICD-9 Code(s): Please DO NOT describe the procedures; only enter the Code, Modifier, and Quantity. 724.5 CPT/HCPCS Mod Qty CPT/HCPCS Mod Qty CPT/HCPCS Mod Qty CPT/HCPCS Mod Qty 12 NOTE: The information being transmitted contains information that is confidential, privileged and exempt from disclosure under applicable law. It is intended solely for the use of the individual or the entity to which it is addressed. If you have received this communication in error, please immediately notify us. Revised: 03/19/2015 Copyright © 2015 DocuStream, Inc. ...
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...III of the your provider manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission. CMS-1500 Billing Procedures - Occupational, Physical, Speech Therapy Procedure Codes The following occupational, physical and speech-language pathology procedure codes are payable for therapy services indicated. Refer to Section IV - Glossary - of your Medicaid provider manual for definitions of “group” and “individual” as they relate to therapy sessions. | | A. Occupational Therapy |Procedure Code |Required |Description | | |Modifiers | | |97003 |— |Evaluation for Occupational Therapy | | | |(30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) | |97530 |— |Individual Occupational Therapy | | | |(15-minute unit; maximum of 4 units per day) | |97150 |U2 |Group Occupational Therapy ...
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Computer - Assisted Coding
...complex coding cases and data analysis tasks. Factors, such as advances in natural language processing, EHR adoption, compliance issues and mandates for labor – intensive administrative reporting processes reduction, influenced the demand of CAC. Traditionally, clinical documentation (whether paper or electronic) is analyzed by a coder, translated into the appropriate ICD – 9 CM or CPT/HCPCS codes with the help of coding books or encoders and entered into a database. These new coding automation tools assists HIM professionals in translating data by automated code assignment instead of manual review and translation alone. As early as the 1950s, the technology of CAC – enabled tools, particularly Natural Language Processing (NLP), started with formal language theory. Throughout this time, technological progress was slow but technology has rapidly progressed and is constantly advancing at an exponential rate since the 1990s. Coding is a difficult task because it has a four- dimensional complexity. First, coding rules’ volume and intricacy makes selecting the right diagnosis/ procedure code and code modifiers difficult. In an article by Yuval Lirov (2009), the author gives example to this level of complexity by stating, “ For instance, a claim will get denied if you charged for two CPT codes but provided an ICD – 9 code that shows medical necessity for one CPT code only” (Lirov 2009). Secondly, the complexity is exacerbated by payer- specific modifications, which creates the......
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...Capstone CheckPoint There are several pieces to a complicated puzzle which is called Medical Billing Process and HIPAA, ICD, CPT and HCPCS contribute their own uniqueness to the process. HIPAA is the umbrella to the process. HIPAA compliance, as far as protecting the patient’s rights and confidentiality and the physician, has to take place first in the medical billing process. HIPAA influences the medical staff in determining financial responsibility, either as private pay, insurance and personal information who is the responsible party. HIPAA statement has to be signed by the patient, giving authorization for who can obtain their personal information. Then ICD, CPT and HCPCS come under the umbrella each filling a specific area of in the process of medical billing. They are references that are used for certain areas, either by patient billing, physicians and medical facilities. ICD are codes that reference the type of service the patient receives while in staying in a hospital. CPT are numerical codes that are assigned by medical coders and dictate the type of procedures that have been completed on a patient. HCPCS codes are used for outpatient services that physicians or medical facilities use to complete the medical billing process. This is a brief overview of each area, but all of them have to fit like a tight glove to avoid errors in billing. When you look into the advanced purpose of each coding device, you see how complex the medical......
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...and intentional conduct to collect payments for services not provided. High Risk Areas the OIG has identified the following risk areas, which could be problematic for physicians (Federal Register, Volume 65, Number 113, "Compliance Program Guidance for Individual and Small Group Physician Practices"): 1. billing for items or services not provided. 2. Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary. 3. Double billing for the same service or item. 4. Billing for non-covered services. 5. Misuse of provider identification numbers. 6. Unbundling a multiple component service and billing each component as a single service. 7. Failure to properly use coding modifiers. 8. Upcoming the level of service provided. Because of its widespread practice, upcoming is a major focus of the OIG and is incorporated into the regulations promulgated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). To illustrate risks associated with improper coding, we will look at the practice of upcoming. Upcoming is defined as "billing for a more expensive service than the one actually performed." Medical record documentation is the evidence of coding and justification for billing. Failure of the physician practice to appropriately document the medical record could result in improper coding and erroneous billing. The Physician's Risk of Upcoming 99214 to 99215 one of the great......
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T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great
AA- Anesthesia services performed by anesthesiologist.
AD- Medical supervision by a physician, more than four concurrent
AH- Clinical Psychologist (CP) Services. [Used when a medical group employs a CP and bills for the CP’s service.
AJ- Clinical Social Worker (CSW). [Used when a medical group employs a
CSW and bills for the CSW’s service.
AM- Physician, team member service
AS- Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery.
AT- Acute treatment. [This modifier should be used when reporting a spinal manipulation service
CC- Procedure code changed. [This modifier is used when the submitted
procedure code is changed either for administrative reasons or because an incorrect code was filed.
G1- Most recent urea reduction ratio (URR) reading of less Than 60.
G2- Most recent urea reduction ratio (URR) reading of 60 to 64.9.
G3- Most recent urea reduction ratio (URR) of 65 to 69.9.
G4- Most recent urea reduction ratio (URR) of 70 to 74.9.
G5- Most recent urea reduction ratio (URR) reading of 75 or greater.
G6- ESRD patient for whom less than six dialysis sessions have been provided in a month.
G7- Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening.
G8- Monitored Anesthesia Care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
G9- Monitored Anesthesia Care (MAC) for patient who has history of severe cardio- pulmonary condition.
GA- Waiver of Liability Statement on file. (Effective for dates of service on or after October 1, 1995, a physician or supplier should use this modifier
to note that the patient has been advised of the possibility of noncoverage.)
GB- Claim being re-submitted for payment because it is no longer covered under a global payment demonstration.
GC- This service has been performed in part by a resident under the
direction of a teaching physician.
GE- This service has been performed by a resident without the presence of a teaching physician under the primary care exception.
GJ- "Opt Out" physician or practitioner emergency or urgent service.
GM- Multiple patients on one ambulance trip.
GN- Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care.
GO- Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care.
GP- Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care.
GQ- Via asynchronous telecommunications system
GV- Attending physician not employed or paid under arrangement by the patient’s hospice provider.
GW- Service not related to the hospice patient’s terminal condition.
GY- Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
GZ- Item or service expected to be denied as not reasonable and necessary.
KO- Single drug unit dose formulation.
KP - First drug of a multiple drug unit dose formulation.
KQ- Second or subsequent drug of a multiple drug unit dose formulation.
LC- Left circumflex coronary artery.
LD- Left anterior descending coronary artery.
LR- Laboratory round trip.
LS- FDA-monitored intraocular lens implant.
LT- Left Side. (Used to identify procedures performed on the left side of the body.)
Q3- Live kidney donor - Services associated with postoperative medical complications directly related to the donation.
Q4- Service for ordering/referring physician qualifies as a service exemption.
Q5- Service furnished by a substitute physician under a reciprocal billing arrangement.
Q6- Service furnished by a locum tenens physician.
Q7- One Class A Finding.
Q8- Two Class B findings.
Q9- One Class B and Two Class C findings.
QA- FDA investigational device exemption.
QB- Physician providing service in a rural Health Professional Shortage area
GT- Via interactive audio and video telecommunication systems.
QC- Single channel monitoring.
QD- Recording and storage in solid state memory by digital recorder.
QK- Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.
QL- Patient pronounced dead after ambulance called.
QM- Ambulance service provided under arrangement by a provider of services.
QN- Ambulance service furnished directly by a provider of services.
QS- Monitored anesthesia care service.
QT- Recording and storage on a tape by an analog tape recorder.
QU- Physician providing service in an urban Health Professional Shortage Area (HPSA).
QV- Item or service provided as routine care in a Medicare qualifying clinical
QW- Clinical Laboratory Improvement Amendment (CLIA) waived test (modifier used to identify waived tests).
QX- CRNA service with medical direction by a physician.
QY- Anesthesiologist medically directs one CRNA.
QZ- CRNA service without medical direction by a physician.
RC- Right coronary artery.
RT- Right Side (used to identify procedures performed on the right side of the body).
SF- Second opinion ordered by a Professional Review Organization (PRO)
SG- Ambulatory Surgical Center (ASC) facility service.
TC- Technical Component.
U1 Perinatal care provider completed prenatal or postpartum depression screening and behavioral health need identified (positive screen)
U2 Perinatal care provider completed prenatal or postpartum depression screening with no behavioral health need identified (negative screen)
U3 Pediatric provider completed postpartum depression screening during well-child or infant episodic visit and behavioral health need identified (positive screen)
U4 Pediatric provider completed postpartum depression screening during well-child or infant episodic visit with no behavioral health need identified (negative screen)
HQ Group counseling, at least 60-90 minutes
TF Intermediate level of care, at least 45 minutes
HA Service Code 90791 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths is included in the assessment. This modifier may be billed only by psychiatrists.
PA Surgical or other invasive procedure on wrong body part
PB Surgical or other invasive procedure on wrong patient
PC Wrong surgery or other invasive procedure on patient
PT modifier - Colorectal cancer screening test; converted to diagnostic test or other procedure.
Modifier Usage Guidelines
To ensure you receive the most accurate payment for services you render, Blue Cross recommends using modifiers when you file claims. For Blue Cross claims filing, modifiers, when applicable, always should be used by placing the valid CPT or HCPCS modifier(s) in Block 24D of the CMS-1500 claim form. A complete list of valid modifiers is listed in the most current CPT or HCPCS code book. Please ensure that your office is using the current edition of the code book reflective of the date of service of the claim. If necessary, please submit medical records with your claim to support the use of a modifier.
Please use the following tips to avoid the possibility of rejected claims:
• Use valid modifiers. Blue Cross considers only CPT and HCPCS modifiers that appear in the current CPT and HCPCS books as valid.
• Indicate the valid modifier in Block 24D of the CMS-1500. We collect up to four modifiers per CPT and/or HCPCS code.
• Do not use other descriptions in this section of the claim form. In some cases, our system may read the description as a set of modifiers and this could result in lower payment for you.
• Avoid excessive spaces between each modifier.
• Do not use dashes, periods, commas, semicolons or any other punctuation in the modifier portion of Block 24D.
Most Used Modifier with detailed description
22—Increased Procedural Services: Documentation is required when billing with this modifier. A short explanation of why this modifier was applied will also help expedite the processing of claims.
24—Unrelated E&M Service by Same Physician During a Postoperative Period: Used when a physician performs an E&M service during a postoperative period for a reason(s) unrelated to the original procedure.
25—Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the Procedure or Other Service: Used by provider to indicate that on the same date of service, the provider performed two significant, separately identifiable services that are not “unbundled”.
26 or PC—Professional Component: Certain procedures are a combination of a physician component and a technical component, and this modifier is used when the physician is providing only the interpretation portion. TC—Technical Component: Certain procedures are a combination of a provider component and a technical component, and this modifier is used when the provider is performing only the technical portion of a service.
32—Mandated Services: Services related to mandated consultation and/or related services (e.g., third party payer, governmental, legislative, or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
47—Anesthesia by Surgeon: Regional or general anesthesia provided by a surgeon may be reported by adding this modifier to the surgical procedure. Amount allowed is 25% of the surgical procedure allowance.
82 Insurance Health Plans Revised September 9, 2016. Replaces all prior versions.
62—Two Surgeons (MD, DMD, DO): When two surgeons work together as primary surgeons performing distinct part(s) of a single procedure, each surgeon should add modifier 62 to the Procedure code. The combined allowable for co-surgeons is 125% of the full Procedure allowable. This amount will be split 50-50 between the two surgeons, unless otherwise indicated on the claim form.
63—Procedure Performed on Infants less than 4kg: Documentation is required when billing with this modifier. A short explanation of why this modifier was applied will also help expedite the processing of claims.
66—Surgical Team (MD, DO, PA, CRNFA, RN, SA): When a team of surgeons (two or more) are required to perform a specific procedure, each surgeon bills the procedure with modifier 66. Fee allowance is increased to 120% of the basic fee allowance for the procedure.
76—Repeat Procedure by Same Physician: This modifier is used to indicate that a repeat procedure on the same day was necessary, or a repeat procedure was necessary and it is not a duplicate bill for the original surgery or service.
77—Repeat Procedure by Another Physician: This modifier is used to indicate that a procedure already performed by another physician is being repeated by a different physician. This sometimes occurs on the same date of service.
78—Return to the OR for a Related Procedure During the Post-op Period: Indicates that a surgical procedure was performed during the post-op period of the initial procedure, was related to the first procedure, and required use of the operating room. This modifier also applies to patients returned to the operating room after the initial procedure, for one or more additional procedures as a result of complications. Documentation is required when billing with this modifier.
79—Unrelated Procedure or Service by the Same Physician During the Post-op Period: Indicates that an unrelated procedure was performed by the same physician during the post-op period of the original procedure.
80—Assistant Surgeon (MD, DMD, DO): Only one first assistant may be reimbursed for a Procedure code, except for open-heart surgery, where two assistants are allowed. Payment will be allowed only if an assistant surgeon is allowed by our claims editing system. The fee allowance is automatically reduced to 20% of the surgical fee allowance as billed by the primary surgeon. Refer to Surgical Assistant Guidelines 11.5.3 of the Provider Manual.
50—Bilateral Procedures: Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day. Unless otherwise identified, bilateral procedures should be identified with this modifier. A separate procedure code should be billed for each procedure, using modifier -50 on the second one. Refer to Bilateral Procedures 11.5.1 of the Provider Manual.
51—Multiple Procedures: Procedures performed at the same operative session, which significantly increase time. Multiple procedures should be listed according to value. The primary procedure should be of the greatest value and should not have modifier -51 added. Subsequent procedures should be listed using modifier -51 in decreasing value. Refer to Bilateral Procedures 11.5.2 of the Provider Manual.
52—Reduced Services: Allowed amount to be reduced to 80% (cut by 20%), then processed according to the contract benefits.
53—Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Allowed amount will be reduced to 75% (cut by 25%), then processed according to contract benefits.
54—Surgical Care Only: Used with surgery procedure codes with a global surgery period only. Fee allowance is reduced to 70% of the original allowed. See modifiers 55 and 56 below for additional details on pre- and post-op care only.
55—Postoperative Management Only: Reimbursement is limited to the post-op management services only. Used with the surgery Procedure code, auto adjudication reduces fee allowance to 30% of the total allowed.
56—Preoperative Management Only: Reimbursement is limited to the pre-op management services only. Used with the surgery Procedure code, auto adjudication reduces fee allowance to 10% of the total allowed.
57—Decision for Surgery: This modifier identifies an E&M service(s) that resulted in the initial decision for surgery and are not included in the “global” surgical package.
59—Distinct Procedural Service: Indicates that a procedure or service was distinct or independent from other services performed on the same day. Example: An E&M service for an ear infection and a surgical code billed for removal of a wart at the same visit.
81—Minimum Assistant Surgeon (CNM, CRNFA, NP, PA, RN, SA): Use this modifier when the services of a second or third assistant surgeon are required during a procedure. Use with surgical Procedure codes only. The allowance is automatically reduced to 10% of the surgical fee allowance as billed by the primary surgeon.
82—Assistant Surgeon: This modifier is used when a qualified resident surgeon is not available. This is a rare occurrence. The fee allowance is automatically reduced to 20% of the surgical fee allance as billed by the primary surgeon.
90—Reference (Outside) Laboratory: This modifier is used when laboratory procedures are performed by a party other than the treating or reporting physician. Allowed should fall to contracted lab fees.
91—Repeat Clinical Diagnostic Laboratory Test: This modifier is used when a provider needs to obtain additional test results to administer or perform the same test(s) on the same day and same patient. It should not be used when the test(s) are rerun due to specimen or equipment error or malfunction. Nor should this code be used when basic procedure code(s) (such as Procedure 82951) indicate that a series of test results are to be obtained.
99—Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to completely describe a service.
JW—JW Modifier is now billable for single dose medications purchased for a specific patient when a portion must be discarded.
SG—Ambulatory Surgery Center: This modifier is used when the services billed were provided at an Ambulatory Surgery Center (ASC).
SU—Procedure performed in physician’s office (to denote use of facility and equipment) CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows (effective January 1, 2015):
• XE—Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
• XS—Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/ Structure
• XP—Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
• XU—Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service Your Insurance Provider Service Representative is available any time you have a question or concern.
Level I (CPT) Modifiers
-25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79, -91
Level II (HCPCS) Modifiers
-CA, -E1, -E2, -E3, -E4, -FA, -FB, -FC, -F1, -F2, -F3, -F4, -F5, -F6, -F7, -F8, -F9, -GA, -GG, -GH, -GY, -GZ, -LC, -LD, -LT, -QL, -QM, -RC, -RT, -TA, -T1, -T2, -T3, -T4, -T5, -T6, -T7, -T8, -T9
Used to identify type of therapy service and level of functional impairment
Outpatient Therapy Code Modifiers – Identify discipline of plan of care under which service is delivered
GNServices delivered under an outpatient speech language pathology plan of care
GOServices delivered under an outpatient occupational therapy plan of care
GPServices delivered under an outpatient physical therapy plan of care
KXUsed to indicate the services rendered are medically necessary
Therapy Functional Modifiers – Used in conjunction with function related G series codes for physical therapy (PT), occupation therapy (OT) and speech language pathology (SLP) to indicate severity/complexity of beneficiary's percentage of functional impairment as determined by clinician furnishing therapy services
CH0 percent impaired, limited or restricted
CIAt least 1 percent but less than 20 percent impaired, limited or restricted
CJAt least 1 percent but less than 20 percent impaired, limited or restricted
CKAt least 40 percent but less than 60 percent impaired, limited or restricted
CLAt least 60 percent but less than 80 percent impaired, limited or restricted
CMAt least 80 percent but less than 100 percent impaired, limited or restricted
CN100 percent impaired, limited or restricted
PORTABLE XRAY HCPCS Modifier Description
UN Two patients served (used with procedure R0075)
UP Three patients served (used with procedure R0075)
UQ Four patients served (used with procedure R0075)
UR Five patients served (used with procedure R0075)
US Six or more patients served (used with procedure R0075)
POSITION EMISSION TOMOGRAPHY (PET) SCAN HCPCS Modifier Description
PI Initial Anti-tumor Treatment Strategy
PS Subsequent Treatment Strategy
PROSTHETICS HCPCS Modifier Description
Ls FDA monitored Intraocular Lens Implant
Common Modifier usage
Modifier 22 can be used on any procedure within the Anesthesia, Surgery, Radiology, Laboratory/Pathology and Medicine series of codes. However, this modifier should not be used on E&M services. E&M codes with a modifier 22 will be denied. If modifier 22 is used on any surgical procedure, then it must only be used on surgeries which have a global period of 000, 010, 090, or YYY identified on the Medicare Physician Fee Schedule Relative Value File
26 50, 62, 66, TC If billing for the global component (professional & technical) of a procedure, modifiers 26 and TC should not be used. Modifier 26 can only be used by professional providers. It should not be used by a hospital. KMAP uses the Medicare Physician Fee Schedule Relative Value file to determine which procedures are appropriately billed with modifier 26. KMAP uses the PT/TC indicator field on the file as a basis to determine proper usage of modifier 26. The following determination has been made based on the individual indicators.
Modifier 47 - This modifier should be appended only to the surgical procedure code when applicable. It is not appropriate to use this modifier on anesthesia procedure codes. The anesthesiologist would not use this modifier. Do not report modifier 47 when the physician reports moderate (conscious) sedation. 50 26, LT, RT, TC KMAP uses the Medicare Physician Fee Schedule Relative Value file to determine which procedures are appropriately billed with modifier 50. KMAP uses the Bilat Surg indicator field on the file as a basis to determine proper usage of modifier 50. 54 55, 56, 80, 81, 82, AS When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical codes can be identified by adding the modifier 54. Physicians who perform the surgery and furnish all of the usual pre- and post-operative work bill for the global package by entering the appropriate CPT® KMAP uses the Medicare Physician Fee Schedule Relative Value file to determine which procedures are appropriately billed with modifier 54. code for the surgical procedure only; therefore, modifiers 54 and 55 cannot be combined on a single detail line item. KMAP uses the Glob Days field on the file as a basis to determine proper usage of modifier 54. The following determinations have been made based on the individual indicators.
58 80, 81, 82, AS It may be necessary to indicate the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. Complications from surgery which do not require a return trip to the operating room are considered part of the global surgery package from the original surgery and are not payable separately. Modifier 58 is not appropriate in this situation.
66 26, 62, 80, 81, 82, AS, TC Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances can be identified by each participating physician with the addition of modifier 66 to the basic procedure code used for reporting services. 73 Submit modifier 73 for ASC facility charges when the surgical procedure is discontinued before anesthesia is administered. This modifier cannot be submitted by the operating surgeon. Only ASCs can submit this modifier. Surgeons can refer to modifier 53.
Modifier 73 is used by the facility to indicate a surgical or diagnostic procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well being of the patient after the patient had been prepared for the procedure (including procedural premedication when provided) and taken to the room where the procedure was to be performed but prior to administration of anesthesia. This modifier code was created so the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) can be recognized for payment even though the procedure was discontinued. 74 Submit modifier 74 for ASC facility charges when the surgical procedure is discontinued after anesthesia is administered. This modifier cannot be submitted by the operating surgeon. Only ASCs can submit this modifier. Surgeons can refer to modifier 53.
Modifier 76 is used when the procedure is repeated by the same physician subsequent to the original service. The repeat service must be identical to the initial service provided. This modifier is separate and distinct from modifiers 58, 78, and 79. Please refer to details for these modifiers.
If the same procedures are performed on the same day, they must be billed on the same claim. If the duplicative service is not billed on the same claim, a duplicate denial of the service will occur. Although valid, this modifier does not document payable services during the global period, therefore rendering this modifier invalid for use with a surgical code. Repeat procedures for treatment of complications can be billed with modifier 78.
Modifier 82 is a processing modifier, and the rate is 25% of the base code. 90 The American Medical Association (AMA) developed modifier 90 for use by a physician or clinic when laboratory tests for a patient are performed by an outside or reference laboratory. Although the physician is reporting the performance of a laboratory test, this modifier is used to indicate the actual testing component was provided by a laboratory.