Provider Modifier Grid
Product Information
UCare products include Commercial, Medicare, and Minnesota Health Care Programs (MHCP). For detailed information regarding the Plans covered under these products refer to UCare's website under health plans.
General Payment Information
The information provided below outlines the impact appending a specific modifier will have on payment of professional claims. Payment for each eligible professional service is based on the lesser of charge, or the increase, decrease or change in payment that is specific to the modifier that has been appended to the service.
Modifiers
Modifiers are used as means to communicate that a service or procedure has been altered by some specific circumstance without changing the description of the service provided, communicate additional information regarding the provider performing the service, provide clarity regarding the service performed, or to meet specific payment policy requirements. Outlined below is general information regarding the use of modifiers and the impact the use of those modifiers may have on payment.
Refer to UCare’s Anesthesia Policies for detailed information the use of and payment associated with the use of anesthesia modifiers.
AA - Anesthesia services performed personally by anesthesiologist.
AD - Medical supervision by a physician: more than four concurrent anesthesia procedures.
GC - Services performed in part by a resident under the direction of a teaching physician.
G8 - Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures.
G9 - Monitored anesthesia care (MAV) for a patient who has a history of severe cardiopulmonary condition.
QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.
QS - Monitored anesthesia care (MAC) services.
QX - Qualified non-physician anesthetist with medical direction by a physician.
QY - Medical direction of one qualified non-physician anesthetist by an anesthesiologist.
QZ - CRNA without medical direction by a physician.
Links to pertinent information:
CMS (IOM), Publication 100-4, Medicare Claims Processing Manual, Chapter 12, Section 50
CMS.gov Anesthesiologists Center
Medicaid/MHCP Provider Manual, Anesthesia
UCare Medicare Anesthesia Policy
UCare MHCP Anesthesia Policy
Physical Status Modifiers provide additional information regarding the overall physical status of the patient, identifying various levels of complexity impacting the patient and the administration of anesthesia. Medicare considers these modifiers to be informational and does not provide any additional payment when any of these modifiers are appended to anesthesia services.
P1 - A normal healthy patient.
P2 - A patient with mild systemic disease.
P3 - A patient with severe systemic disease.
P4 - A patient with severe systemic disease that is a constant threat to life.
P5 - A moribund patient who is not expected to survive without the operation.
P6 - A declared brain-dead patient whose organs are being removed for donor purposes.
Links to pertinent information:
CMS (IOM), Publication 100-4, Medicare Claims Processing Manual, Chapter 12, Section 50
CMS.gov Anesthesiologists Center
Medicaid/MHCP Provider Manual, Anesthesia Services
59 - Distinct Procedural Service.
XE - Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter.
XP - Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner.
XS - 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.
Links to pertinent information:
EM - Emergency Reserve Supply (For ESRD benefit only).
For patients beginning to self-administer an ESA at home receiving an extra month supply of drug, bill one-month reserve supply on one claim line and append the -EM modifier.
Links to pertinent information:
All hemodialysis claims must indicate the most recent URR for dialysis patient. Submit CPT code 90999 (unlisted dialysis procedure, inpatient or outpatient) to be reported in field location 44 for all bill types 72X. One of the modifiers listed below must be appended to the claim line.
Modifiers G1-G5 are used for patients who received seven or more dialysis treatments in a month.
Modifier G6 is used for patients who have received dialysis six days or fewer in a month.
G1 - Most recent Urea Reduction Ration (URR) reading of less than 60%.
G2 - Most recent URR reading of 60% to 64.9%.
G3 - Most recent URR reading of 65% to 69.9%.
G4 - Most recent URR reading of 70% to 74.9%.
G5 - Most recent URR reading of 75% or greater.
G6 - ESRD patient for whom fewer than seven dialysis sessions have been provided in a month.
Links to pertinent information:
AY - Item or service furnished to an ESRD patient that is not for treatment of ESRD.
The ESRD prospective payment system (PPS) includes consolidated billing for limited Part B services included in ESRD facility bundled payment. When laboratory services and limited drugs are provided to a patient but are not related to treatment for ESRD, claim lines must be submitted with AY modifier to allow for separate payment outside of ESRD PPS.
Links to pertinent information:
One of the modifiers listed below must be appended to the claim line to specify the type of administration used for ESA for ESRD.
JA - Intravenous injection administration of ESA for ESRD.
JB - Subcutaneous injection administration of ESA for ESRD.
JE - Append this modifier to all ESRD claims where drugs and biologicals are furnished via dialysate solution.
Links to pertinent information:
KX - Any medically necessary extra beyond the monthly maximum. The documentation in the patient's medical record must support the reason why extra hemodialysis sessions were given beyond the frequency.
Any medically necessary extra hemodialysis sessions beyond the monthly maximum must be indicated on the claim form with the use of CPT 90999 and the KX modifier.
Links to pertinent information:
Medicare Benefit Policy Manual, Publication 100-02, Chapter 11, Section 50A(1)
Medicare Claims Processing Manual, Publication 100-04, Chapter 8, Section 50.6.2
CG - ESRD facilities billing for more than 13 or 14 treatments per month must provide medical justification to receive payment for the additional treatments. Additional treatments provided without meeting the medical justification required must append the -CG modifier on the claim line. This modifier indicates that the facility attests the additional treatment does not meet medical justification requirements.
Links to pertinent information:
Q3 - Liver Kidney Donor Surgery and Related Services
All eligible physicians’ services rendered to the living donor and all physicians' services rendered to the transplant recipient are billed to the Medicare program in the same manner as all Medicare Part B services are billed. All donor physicians' services must be billed to the account of the recipient (i.e., the recipient's Medicare number). The -Q3 modifier (Live Kidney Donor and Related Services) should be appended to the claim line(s).
Links to pertinent information:
Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3, Section 90
ESRD claims for hemodialysis must indicate type of vascular access used and whether an infection was present at the time of treatment.
V5 - Vascular catheter (alone or with any other vascular access).
V6 - Arteriovenous graft (or other vascular access not including a vascular catheter in use with two needles).
V7 - Arteriovenous fistula only (in use with two needles).
Links to pertinent information:
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.9
The modifiers listed below are specific to mental health services eligible for coverage under one of UCare’s State Public Programs or dual eligible products. Refer to UCare’s Mental Health Policies for detailed information regarding the services requiring a modifier(s) and the correct use of each modifier associated with the service.
AG - Primary Care Provider Receiving Psychiatric Consultation
AM - Consulting Psychiatrist to Primary Care Provider
HA - Child or Adolescent
HE - Mental Health
HK - Intensive or Children’s Day Treatment
HM - Adult MH Rehabilitation Worker or Mental Health Behavioral Aide Level II
HN - Qualified Mental Health Practitioner or Bachelor Degree Level (Clinical Trainee)
HQ - Group Modality
HR - Family/Couple with Client Present
HS - Family/Couple without Client Present
TG - Extended Diagnostic Update/Psychiatric Consultation complex/lengthy
TS - Adult Diagnostic Update
UA - CTSS service package/Children's crisis service package
UB - Children's Clinical Care Consultation - 21 to 30 minutes
UC - Children's Clinical Care Consultation - 31 minutes and above
UD - MH Assessment, Physician Administered Claims
U1 - Dialectical Behavior Therapy (DBT)
U3 - ARMHS Transitioning to community living
U4 - Service provided via non face-to-face contact, e.g., telephone
U5 - Certified Peer Specialist Level II
U6 - Interactive Behavioral Health Day Treatment
U8 - Child Children's Clinical Care Consultation - 5 to 10 minutes
U9 - Children's Clinical Care Consultation - 11 to 20 minutes
52 - Brief Diagnostic Assessment
Links to pertinent information:
24 - Unrelated Evaluation and Management (E&M) Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.
The -24 modifier should be appended to an E&M service or eye exam performed within the global period of a major (90 days) or minor surgery (10 days) performed by a surgeon to indicate that the E&M service is unrelated to the surgery.
It is not necessary to submit supporting documentation with the claim. However, UCare reserves the right to request supporting documentation that indicates the E&M service is unrelated to the surgery. Supporting documentation must be made available upon request.
25 - Significant, Separately Identifiable Evaluation and Management (E&M) Service by the Same Physician or Other Qualified Health Care Professional on the Same Day the Procedure or Other Service.
The -25 modifier should be appended to a service to indicate that on the day a procedure or service was performed, the patient's condition required a significant, separately identifiable E&M service above and beyond other service provided.
It is not necessary to submit supporting documentation with the claim. However, UCare reserves the right to request documentation to support that the E&M service is unrelated to surgery. Supporting documentation must be made available upon request.
57 - Decision for Surgery.
Links to pertinent information:
Medicare Learning Network (MLN) Matters Global Surgery Fact Booklet
CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.6.6 and 40.2
Medicaid/MHCP Provider Manual, Physician and Professional Services
22 - Increased Procedural Services
This should only be used when documentation indicates work performed is substantially greater than typically required by technical difficulty, severity of patient's condition or increased intensity and time.
Links to pertinent information:
50 - Bilateral Procedure
The -50 modifier must be appended to diagnostic and radiology procedures and surgical procedures. Report bilateral procedures that are performed at same operative session as a single line item. Modifiers RT and LT are not used when modifier 50 applies.
A bilateral procedure is reported on a single claim line.
Links to pertinent information:
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.7
Medicaid/MHCP Provider Manual, Physician and Professional Services, Surgical Services
51 - Multiple Procedures
This modifier is informational. When multiple procedures are performed on the same day, claim payment will be determined based on the allowed amount for each procedure. The highest valued procedure will be paid as primary and the remaining procedures will be paid as secondary procedures.
Links to pertinent information:
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.6
52 - Reduced Services
Links to pertinent information:
53 - Discontinued Procedure
Links to pertinent information:
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.1
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 60.2
54 - Surgical Care Only
55 - Postoperative Management Only
56 - Preoperative Management Only
Links to pertinent information:
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40
Medicare Learning Network (MLN) Matters Global Surgery Booklet
58 - Surgical Care Only
Stage or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
The -58 modifier indicates the procedure(s) performed during the postoperative period of another surgical procedure when subsequent procedure(s) was planned prospectively at time of original procedure, a less extensive procedure fails and a more extensive procedure is required or a therapeutic surgical procedure follows a diagnostic procedure.
Links to pertinent information:
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40
Medicare Claims Processing Manual Chapter 4, Section 20.6
Medicare Learning Network (MLN) Matters Global Surgery Booklet
62 - Two Surgeons
The MPFSDB professional fee schedule includes an Indicator Co-Surgeon (Two surgeons) (CO-SURG). Indicator 1 and 2 identifies services which must be sufficiently documented to establish that a co-surgeon was medically necessary.
The base allowed amount for eligible co-surgeon payment is 62.5% of UCare’s global surgery fee schedule amount.
Links to pertinent information:
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.8
Medicare Learning Network (MLN) Matters Global Surgery Booklet
63 - Procedure Performed on an Infant Less Than 4kg
66 - Surgical Team
HCPCS/CPT© codes on the MPFSDB professional fee schedule with a Team Surgery Indicator (TEAM SURG) of 1 and 2 may be eligible for team surgery reimbursement. Each surgeon should submit a claim and an operative report and any other supporting documentation for the surgery performed. Modifier -66 should be appended to each HCPCS/CPT© code submitted. Team surgeons should submit the same HCPCS/CPT© codes. Payment will be determined based on review of the documentation submitted. Claims submitted without documentation will be denied.
When multiple surgical procedures are performed, multiple surgery guidelines do apply.
Links to pertinent information:
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.8
Medicare Learning Network (MLN) Matters Global Surgery Booklet
78 - Unplanned Return to the Operating / Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure During the Postoperative Period.
Links to pertinent information:
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.2, 40.8
Medicare Learning Network (MLN) Matters Global Surgery Booklet
79 - Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
Append the -79 modifier to indicate that a procedure or service furnished during a postoperative period was unrelated to the original procedure. A new post-operative period begins when unrelated procedure is billed.
Links to pertinent information:
Medicare Claims Processing Manual, Chapter 12, Sections 30 and 40.2
Medicare Learning Network (MLN) Matters Global Surgery Booklet
80 - Assistant Surgeon
81 - Minimal Assistant Surgeon
82 - Assistant Surgeon (when qualified resident surgeon not available)
AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assist at surgery.
Links to pertinent information:
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 20.4.3
Medicare Learning Network (MLN) Matters Global Surgery Booklet
Additional Resources
Medicare
- CMS National Correct Coding Initiative (NCCI)
- CMS Medically Unlikely Edits (MUEs)
- CMS IOM, Publication 100-04, Medicare Claims Processing Manuals
- MLN Global Surgery Fact Sheet
Medicaid / MHCP
Disclaimer
The following disclaimer applies to the modifier grid published by UCare and all of the UCare’s published attachments provided therein.
The examples provided above are for illustrative purposes only, and are not intended to be a guarantee of coverage or payment.
Payment policies assist in administering payment for UCare benefits under UCare’s health plans. Payment policies are intended to serve only as a general reference resource regarding UCare’s administration of health benefits and are not intended to address all issues related to payment for health care services provided to UCare members. In particular, when submitting claims, all providers must first identify member eligibility, federal and state legislation or regulatory guidance regarding claim submission, UCare provider participation agreement contract terms, and member specific Evidence of Coverage (EOC) or other benefit documents. In the event of a conflict, these sources supersede the Payment Policies. Payment Policies are provided for informational purposes and do not constitute coding or compliance advice. Providers are responsible for submission of accurate and compliant claims. In addition to Payment Policies, UCare also uses tools developed by third parties, such as the Current Procedural Terminology (CPT®*), InterQual guidelines, Centers for Medicare and Medicaid Services (CMS), the Minnesota Department of Human Services (DHS), or other coding guidelines, to assist in administering health benefits. References to CPT© or other sources in UCare Payment Policies are for definitional purposes only and do not imply any right to payment. Other UCare Policies and Coverage Determination Guidelines may also apply. UCare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary and to administer payments in a manner other than as described by UCare Payment Policies when necessitated by operational considerations.”
*CPT® is a registered trademark of the American Medical Association