[provider/nav_loc.htm]

DHS Outpatient Prospective Payment System (OPPS) HCPCS Modifiers

MODIFIER DOCUMENT

The modifier document represents HCPCS (Level 1 [CPT], Level II [National alpha numeric]) modifiers that DHS reviewed for the Outpatient Prospective Payment System (OPPS) project.

  • The first part of the modifier document identifies specific modifiers (column 1) and if a specific modifier is applicable or not applicable to a procedure code category (columns 2, 3, 4, 5, and 6 of the chart).
  • The rest of the modifier document reflects individual modifier descriptions and DHS billing/payment information.

 

MODIFIER E&M MEDICINE SURGERY X-RAY LAB
21 (prolong E/M) A NA NA NA NA
22 (extensive) A A A A NA
25 (separate) A NA NA NA NA
27 (multiple) A NA NA NA NA
50 (bilateral) NA A A A NA
51 (secondary) NA NA NA NA NA
52 (reduced) NA A A A NA
53 (discontinued) NA NA NA NA NA
58 (staged) NA A A NA NA
59 (distinct) NA A A A NA
73 (discontinued) NA A A A NA
74 (discontinued) NA A A A NA
76 (repeat) NA A A A NA
77 (repeat) NA A A A NA
78 (return to or) NA A A NA NA
79 (unrelated) NA A A A NA
91 (repeat lab) NA NA NA NA A
99 (multiple) NA A A A NA
E1-F9 (lt/rt hand) NA NA A A NA
GH (dx mammo) NA NA NA A NA
LC/LD (lt coronary) NA A NA NA NA
LT/RT (left/right) NA A A A NA
RC (rt coronary) NA A NA NA NA
TA-T9 (lt/rt foot) NA NA A A NA

 

General procedure code categories: Does not include the Level II and III codes.

E & M = 99201-99499
Laboratory = 80000 - 89999
Medicine = 92000-99199
Radiology = 70000 - 79999
Surgery = 10000 - 69999

(A) Applicable = modifier applies to services within the category (E & M, medicine, surgery, lab or radiology)
(NA) Not applicable = modifier does not apply to services within the category (E & M, medicine, surgery, lab or radiology)

 

MODIFIERS
  • 21 = PROLONGED EVALUATION AND MANAGEMENT SERVICES. Modifier 21 will cause the claim to pend for review of the 21 modified line item. Bill on paper and attach a report detailing the prolonged/extensive nature of the service. Modifier 21 logic has changed from prior to 08/01/00.

  • 22 = UNUSUAL PROCEDURE SERVICES. Modifier 22 will cause the claim to pend for review of the 22 modified line item. Bill on paper and attach a report detailing the prolonged/extensive nature of the service. Modifier 22 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • 25 = SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF A PROCEDURE OR OTHER SERVICE. Modifier 25 will determine whether or not separate payment will be made for an E & M service provided on the same day as another procedure or service provided by the same physician. Modifier 25 logic has changed from prior to 08/01/00.

  • 27 = MULTIPLE OUTPATIENT HOSPITAL EVALUATION AND MANAGEMENT ENCOUNTERS ON THE SAME DATE. Modifier 27 will determine whether or not payment will be made on more than one E & M service, of the same procedure code, on the same day. Modifier 27 logic has changed from prior to 08/01/00.

  • 50 = BILATERAL PROCEDURE. Bilateral surgical services are to be billed on one line with a 50 modifier. Bilateral nonsurgical services may be billed on one line with a 50 modifier or on two lines with the appropriate left and right modifiers. Please do not submit a 50 modifier on those procedures that state "bilateral" or "unilateral or bilateral" within the procedure code description. Modifier 50 logic has changed from prior to 08/01/00.

  • 51 = MULTIPLE PROCEDURES. Modifier 51 is no longer appropriate to outpatient hospital UB-92 facility billing. Modifier 51 logic has changed from prior to 08/01/00.

  • 52 = REDUCED SERVICE. Modifier 52 is appropriate to a terminated surgical procedure that typically doesn't require anesthesia or where anesthesia was not an inherent part of the procedure. Please refer to modifiers 73 and 74 for terminated surgical procedure that typically do require anesthesia. Modifier 52 logic has changed from prior to 08/01/00.

  • 53 = DISCONTINUED PROCEDURE. For outpatient hospital facility billing, the 53 modifier has been replaced by modifiers 52, 73 and 74 for outpatient hospital facilities. Modifier 53 is no longer appropriate to outpatient hospital UB-92 facility billing. Modifier 53 logic has changed from prior to 08/01/00.

  • 58 = STAGED OR RELATED PROCEDURE OR SERVICE BY SAME PHYSICIAN DURING THE POSTOPERATIVE PERIOD ON THE SAME CALENDAR DAY. Modifier 58 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • 59 = DISTINCT/SEPARATE PROCEDURE PERFORMED SAME PATIENT/SAME DAY/MAY OR MAY NOT BE SAME PROVIDER. Modifier 59 represents (a) a different procedure or surgery; (b) different site or organ system; (c) separate incision; (d) separate injury or different session or patient encounter. Modifier 59 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • 73 = DISCONTINUED PROCEDURE PRIOR TO ADMINISTERING ANESTHESIA. Procedure cancelled subsequent to patient's diagnostic/surgical prep but prior to the administration of anesthesia. Modifier 73 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • 74 = DISCONTINUED PROCEDURE FOLLOWING ADMINISTRATION OF ANESTHESIA. Modifier 74 payment logic has changed from prior to 08/01/00. Prior to 08/01/00 it paid at 50%.

  • 76 = REPEAT PROCEDURE BY SAME PHYSICIAN.

  • 77 = REPEAT PROCEDURE BY A DIFFERENT PHYSICIAN
    • 76 and 77 modified non-surgical services
      • Multiples of the same non-surgical procedure code are submitted with the first line reflecting one unit, no modifier. The following is the performed number of units beyond one, and modifier 76 or 77. Multiple units, beyond the first unit, are billed on a non-surgical line.


    • 76 and 77 modified surgical services
      • Multiples of the same surgical procedure code are submitted with the first line reflecting one unit, no modifier. The following line is one unit, and modifier 76 or 77. The next following line (if more than two units are provided) is one unit, and modifier 76 or 77. No more than one unit may be billed on a surgical service line.


      Modifiers 76 and 77 logic has changed from prior to 08/01/00.

  • 78 = RETURN TO OPERATING ROOM FOR A RELATED PROCEDURE. Modifier 78 reflects that a subsequent procedure relates to the first procedure and that the subsequent procedure requires the use of an operating room. Payment of 78 modified services will be considered separately from non-modified. Therefore, a 78 modified service may generate a second primary payment of the service date. Modifier 78 logic has changed from prior to 08/01/00. Modifier 78 will cause the claim to pend for review, but the provider will not need report.

  • 79 = UNRELATED PROCEDURE OR SERVICE BY SAME PHYSICIAN. Modifier 79 indicates that the same physician performed a service during the post op period and that the service was unrelated to the original procedure performed. Payment of 79 modified services will be considered separately from non-modified services. Therefore, a 79 modified service may generate a second primary payment of the service date. Modifier 79 logic has changed from prior to 08/01/00.
  • 91 = REPEAT CLINICAL DIAGNOSTIC LABORATORY. Modifier 91 indicates that a clinical diagnostic lab required repeating. Modifier 91 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00, although modifier 91 has been assigned as a valid modifier to individual procedure codes that did not previously have modifier 91 assigned.

  • 99 = MULTIPLE. Modifier 99 identifies that multiple modifiers apply to the service provided. Please submit an explanation detailing all of the modifiers appropriate to the service. Modifier 99 will cause the claim to pend for review of the 99 modified line item. If modifier 99 is submitted on a line, no other modifier should be present on that line. Modifier 99 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • E1 - E4 = UPPER/LOWER AND RIGHT/LEFT EYELIDS. Modifiers E1 through E4 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • F1 - F9 = LEFT/RIGHT AND DIGITS OF HAND. Modifiers F1 through F9 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • GH = DIAGNOSTIC MAMMOGRAM. Modifier GH logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • LC/LD = LEFT CORONARY ARTERY. Modifiers LC and LD logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • LT/RT = LEFT AND RIGHT. Modifiers LT and RT logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00. Bilateral surgical procedures should be submitted on one line with a 50 modifier.

  • RC = RIGHT CORONARY ARTERY. Modifier RC logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • TA - T9 = LEFT/RIGHT AND DIGITS OF TOE. Modifiers TA through T9 logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.

  • TC = TECHNICAL COMPONENT. Modifier TC is not required on the UB-92. DHS assumes TC for radiology billed on the UB-92. Modifier TC logic is the same, effective service date 08/01/00 and after, as prior to 08/01/00.
[Provider/ssi/ssi_cpt.htm]