Monday, June 14, 2010

Medicare claim modifers

Other Modifiers for Medicare Claims

AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination. No effect on payment.
AQ Physician providing a service in an unlisted health professional shortage area (HPSA). For dates of service on or after January 1, 2006.
AT Acute treatment (chiropractic claims) - This modifier should be used when reporting CPT codes 98940, 98941, 98942 or 98943 for acute treatment.No effect on payment.
CC Procedure code change- CARRIER USE ONLY - Used by carrier to indicate that the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed. No effect on payment. Payment determination will be based on the "new" code used by the carrier.
EA Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy.
EB Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy.
EC Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy.
EM Emergency reserve supply (for ESRD benefit only) - No effect on payment.
ET Emergency treatment - Use to designate a dental procedure performed in an emergency situation. No effect on payment.
FB Item provided without cost to provider, supplier or practitioner, or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples)
GA Waiver of liability statement on file - Use to indicate that the physician's office has a signed advance notice retained in the patient's medical record. The notice is for services that may be denied by Medicare. No effect on payment; however, potential liability determinations are based in part on the use of modifier. Updated description effective April 1, 2010: Waiver of Liability Statement Issued, as Required by Payer Policy. This modifier should be used to report when a required ABN was issued for a service.
GH Only for claims with DOS 10/1/98-12/31/01.
GJ Opted Out physician or practitioner - Use to indicate services performed in an emergency or urgent service.
GS Dosage of EPO or Darbepoetin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.
GV Attending physician not employed or paid under agreement by the patient's hospice provider.
GW Service not related to the hospice patient's terminal condition.
GX (Effective 4/1/10) Notice of Liability Issued, Voluntary Under Payer Policy. This modifier should be used to report when a voluntary ABN was issued for a service.
GY Use to indicate when an item or service statutorily excluded or does not meet the definition of any Medicare benefit.
GZ Use to indicate when an item or service expected to be denied as not reasonable and necessary. Used when no Advanced Beneficiary Notice (ABN) signed by the beneficiary.)
G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening.
JA Administered intravenously.
JB Administered subcutaneously.
KB Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim.
KX Updated description effective April 1, 2010: Requirements specified in the medical policy have been met. May be used when a therapy exception is appropriate or should be billed with any procedure code(s) that are gender specific for the affected beneficiaries.
KM Replacement of facial prosthesis - including new impression/moulage
KN Replacement of facial prosthesis - Using previous master model
M2 Medicare Secondary Payer
QC Single channel monitoring - No effect on payment.
QD Recording and storage in solid state memory by a digital recorder - No effect on payment.
QJ Services/items provided to a prisoner or patient in state or local custody, however the State or Local government, as applicable, meets the requirements in 42 CFR 411.4(B)
QT Recording and storage on tape by an analog tape recorder - No effect on payment.
Q3 Live Kidney Donor Surgery and Related Services - No effect on payment.
Q4 Service for ordering/referring physician qualifies as a service exemption -No effect on payment.
Q5 Service furnished by a substitute physician under a reciprocal billing arrangement - No effect on payment.
Q6 Service furnished by a locum tenens physician - No effect on payment.
SK Member of high risk population (Use only with codes for immunization)
32 Mandated services - Services related to mandated consultations and/or related services (e.g., third party payer, governmental, legislative or regulatory requirement) may be identified by adding the modifier '-32' to the base procedure.
59 Distinct Procedural Service - Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier '59' is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier '59' only if no more descriptive modifier is available, and the use of modifier '59' best explains the circumstances, should modifier '59' be used.

Correct Coding Initiative (CCI) Modifier:
Modifier 59 does not replace modifiers 24, 25, 50, 51, 78, 79, RT, and LT
Modifier 59 is not used on Evaluation and Management CPT codes.
99 Multiple modifiers-Use only when more than four modifiers are needed to describe a service. The additional modifiers should be included with the claim (item 19 on paper submissions, or appropriate message or freeform area on electronic submissions). No effect on payment; however, the individual modifiers listed will apply, including any potential effect they may have on payment.

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