June 22, 2005
Pricing Modifiers Reminder
CIGNA Government Services would like to remind all providers that it is imperative when submitting claims containing pricing modifiers, that the pricing modifier should be suffixed as the first modifier listed with each applicable procedure code. This will help to ensure appropriate pricing and payment of the claim.
For example:
A physician's office needs to bill for the interpretation of a chest x-ray, in which the Medicare beneficiary signed an Advance Beneficiary Notice (ABN).
| Step 1: | Select appropriate CPT code: 71010 |
| Step 2: | Append applicable pricing modifiers first: -26 modifier, to indicate the professional component of the x-ray |
| Step 3: | Append all other non-pricing modifiers: -GA modifier, to indicate that the patient signed an ABN |
The claim should be reported with the following line item detail:
71010-26GA
Keep in mind that any modifier affecting the pricing of the claim should be reported in the first modifier position of Item 24d of the CMS-1500 claim, or the electronic equivalent. The reporting of non-pricing modifiers in the first modifier position, where pricing modifiers are listed in a subsequent position, may lead to claim rejections or denials.
The list of modifiers that follows is not intended to be an all inclusive list. It includes the more commonly used modifiers that may determine pricing, and therefore, should be suffixed as the first modifier listed with the applicable procedure code, for appropriate pricing of the claim.
|
22 |
Unusual procedural services When the service(s) provided is greater than what is usually required for the listed procedure, add modifier 22 to the usual procedure code reported. |
|
26 |
Professional component Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure. |
|
50 |
Bilateral procedures Bilateral procedures performed in the same operative session should be reported with modifier 50. |
|
51 |
Multiple procedures Records will be requested when more than a total of five surgeries are billed using a 50 and/or 51 modifier. |
|
52 |
Reduced services Under certain circumstances a service or procedure is partially reduced or eliminated at the physician' election. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. |
|
53 |
Discontinued procedure Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient. To indicate a surgical or diagnostic service that was started but discontinued add the modifier 53 to the usual code for the service to indicate a discontinued procedure. If this modifier is used with a procedure code other than CPT code 45378 (colonoscopy), the claim is subject to medical review and priced by individual consideration. |
|
54 |
Surgical Care Only This modifier is used with surgical codes when only the surgical service was performed. (Another physician is responsible for the pre and/ or post-operative management.) Payment will be limited to the amount allotted to the pre-operative and intra-operative services only. |
|
55 |
Post-operative Management Only Used with surgical codes to indicate that only the post-operative care was performed. (Another physician performed the surgery.) Payment will be limited to the amount allotted for the post-operative services only. |
|
62 |
Two surgeons Co- surgery refers to a single surgical procedure which requires two surgeons of different specialties, or involves two surgeons of the same or different specialties performing parts of the same procedure. Each physician who performed a part of the co-surgery should bill for his/her services by appending modifier 62 to the procedure code. |
|
66 |
Surgical team If a team of surgeons of different specialties (more than 2) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier 66. All claims for team surgeons must contain sufficient information to allow pricing "by report." |
|
78 |
Return to the Operating Room for a related procedure during the post-operative period |
|
80 |
Assistant at surgery Records will be requested when the procedure is one in which an assistant at surgery is used in less than 5% of the cases nationally, and the procedure is not listed as one where an assistant surgeon is not payable due to statutory exclusion. |
|
AA |
Anesthesia services personally furnished by anesthesiologist. |
|
AD |
Anesthesia services medically supervision by a physician, more than four concurrent procedures. |
|
AS |
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Assistant at surgery |
|
QK |
Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. |
|
QW |
CLIA-waived test |
|
QX |
CRNA Service, with medical direction by a physician |
|
QY |
Medical direction of one CRNA by an anesthesiologist |
|
QZ |
CRNA without medical direction by a physician |
|
TC |
Technical Component Certain procedures are a combination of a physician component and a technical component. When the technical component is reported separately, the service may be identified by adding the modifier TC to the usual procedure. |
There may be situations in which your claim reflects more than one pricing modifier. Based on system logic, the following pricing modifiers are valid for the first modifier field only:
| AA | SF |
| AD | TC |
| QK | QT |
| QX | QW |
| QY | 26 |
| UN | 90 |
| UP | |
| UQ | |
| UR | |
| US |
