Facets Functional Modifier Pricing
Updated March 2009

-22

Increased Procedural Services

The reimbursement for a procedure already takes into account that sometimes the procedure will be more simple or sometimes more difficult than normal.  However, there are times when a procedure may be significantly more difficult.  Operative note(s), and for large specimens pathology report(s), are required for services billed with a modifier – 22 modifier.  The documentation must support that the services provided are greater than those usually required for the listed procedure.  It is the responsibility of the surgeon to submit all necessary information.

Additional reimbursement for modifier -22 is only considered for CPT codes having global periods of 0, 10, or 90 days on the National Physician Fee Schedule Relative Value File.

CPT codes not having global periods of 0, 10, or 90 days include codes for Evaluation and Management services (99201-99499), pathology and laboratory services, and most radiology services.  Additional reimbursement for modifier -22 is not allowed for anesthesia codes (00100-01999).  The base unit values for anesthesia codes are taken from the current years American Society of Anesthesiologists (ASA) Relative Value Guide.  Additional units are not eligible to be added to the ASA base value for additional difficulty.

After appropriate use of modifier is validated, reimbursement will be at an additional 20% of the allowable.

-24

Unrelated Evaluation & Management Service by the Same Physician During a Post-operative Period

Reimbursement is at the billed charges or the allowable for the Evaluation and Management CPT code submitted whichever is less.

-25

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

Reimbursement is at the billed charges or the allowable for the Evaluation and Management CPT code submitted whichever is less.  Regence does not deny payment for CPT evaluation and management (E&M) codes with a CPT modifier -25 appended when submitted with surgical or other procedure codes for the same patient on the same date of service based solely on the existence of the modifier -25.

-26

Professional Component

The Centers for Medicare and Medicaid Services (CMS) publishes the National Physician Fee Schedule. This publication includes which CPT and HCPCS codes are eligible for reimbursement for modifier -26. In the absence of a CMS professional for professional indicator, Regence BlueShield of Idaho may establish a  professional designation.

When the procedure code submitted is defined as eligible for modifier –26, reimbursement will be at billed charges or the professional component associated with the modifier –26 fee schedule, whichever is less.

-27

Multiple Outpatient Hospital Evaluation & Management Encounters on Same Date

The use of the modifier is for reporting the use of Evaluating and Management services provided by physician(s) in more than one outpatient hospital setting(s).

-32

Mandated Services

The use of the modifier is to indicate mandated health care services such as court-ordered evaluations, third-party involvement, governmental, legislative or regulatory requirements.

-47

Anesthesia by Surgeon

No additional reimbursement is allowed for anesthesia by a surgeon, assistant surgeon, nursing staff or any other non-anesthesiologist professional during a procedure. Reimbursement for anesthesia by the surgeon is included in the base five digit surgical CPT code.

-50

Bilateral Procedure

CMS publishes the National Physician Fee Schedule. This publication indicates which CPT and HCPCS codes are eligible for reimbursement with modifier -50.  Regence BlueShield of Idaho reimburses bilateral procedures based on the CMS list of procedure codes eligible for modifier -50.

Procedure codes eligible for modifier –50 should be billed as one line item with ‘1’ in the units field. Reimbursement as the primary procedure is at billed charges or 150% of the allowable, whichever is less. Reimbursement as the secondary procedure is at billed charges or 100% of the allowable, whichever is less.

Certain procedure codes, usually radiology procedures or diagnostic tests, are eligible for Modifiers –RT/ -LT or '2' in the units field or Modifier --50. The usual payment adjustment for bilateral procedures (150%) does not apply. These procedure codes are assigned an indicator of '3' by CMS and will be reimbursed without multiple procedure fee reduction.  Indicator ‘3’ codes billed with modifier -50 are reimbursed at billed charges or at 200% of the base code fee schedule, whichever is less.

-51

Multiple Procedures

Regence BlueShield of Idaho follows the American Medical Association (AMA) CPT guidelines and the CMS Multiple Procedure Indicators in determining which codes are eligible for multiple procedure reduction.  Codes listed in the AMA CPT book as modifier 51 exempt CPT Codes are not subject to the multiple procedure reduction. Codes listed in the AMA CPT book as add-on billing codes will be processed and separately reimbursed without reducing payment under the multiple procedure logic provided that the AMA CPT book provides that such add-on CPT Codes are appropriately billed with the proper primary procedure code.   

If a claim with multiple procedures including a procedure or procedures eligible for modifier -51 is billed without using modifier -51, Regence BlueShield of Idaho identifies the procedure with the highest allowable as the primary procedure.  The primary procedure is reimbursed at the lesser of billed charges or 100% of the fee schedule.  Regence BlueShield of Idaho’s reimbursement guideline is to reimburse multiple procedures eligible for modifier -51 at the lesser of billed charges or 50% of the fee schedule.  Regence BlueShield of Idaho’s claims payment system may not be able to follow this reimbursement guideline if multiple procedures are billed inappropriately without modifier -51 AND if the billed charge is less than 50% of the fee schedule for the procedure.

-52

Reduced Services

Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s election.  Under these circumstances, the service provided should be identified by its usual procedure code number and the addition of modifier –52 signifying that the service was reduced.  This provides a means of reporting reduced services without disturbing the identification of the basic service.

-53

Discontinued Procedure

The discontinued procedure will be reimbursed at billed charges or 25% of the allowance for the eligible, primary procedure, whichever is less.

-54

Surgical Care Only

-55

Postoperative Management Only

-56

Preoperative Management Only

Reimbursement is at billed charges or based on the CMS assigned percentages for this modifier, whichever is less. Regence BlueShield of Idaho utilizes these CMS designations in determining procedure code/modifier combinations that are valid for Regence BlueShield of Idaho’s use. In the absence of a CMS modifier 56 indicator, Regence BlueShield of Idaho may establish a modifier 56 designation.

Use of modifier –56 does not include intra-operative work.

When one physician performs the preoperative care and evaluation and another physician performs the surgical procedure, the preoperative component may be identified by adding the modifier –56 to the five-digit surgical code.

-57

Decision for Surgery

An Evaluation and Management code with modifier –57 is eligible for reimbursement when it represents the initial decision to perform a major surgical procedure. Major surgical procedure is defined as a procedure having a 90-day global period .  Modifier –57 is not eligible when appended to an Evaluation and Management code when the Evaluation and Management visit is for the preoperative history and physical prior to the surgical procedure.

-58

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Effective 9/15/2004, reimbursement for approved procedures will be at billed charges or 100% of the allowable, whichever is less.

 

-59

Distinct Procedural Service

CPT codes submitted with modifier 59 attached will be eligible for payment to the extent they follow the AMA CPT book and they designate a distinct or independent procedure performed on the same day by the same physician, but only to the extent that: (1) although such procedures or services are not normally reported together they are appropriately reported together under the particular presenting circumstances; and (2) it would not be more appropriate to append any other CPT recognized modifier to such CPT codes.
Regence does not deny payment for services with a CPT modifier -59 appended based solely on the existence of the modifier -59.

-62

Two Surgeons

CMS publishes the National Physician Fee Schedule. This publication includes which CPT and HCPCS codes are eligible for reimbursement for modifier -62.  Regence BlueShield of Idaho reimburses modifier -62 based on the CMS list of procedure codes eligible for modifier -62.

Two surgeon (co-surgeon) reimbursement involves dividing 125% of the total allowance equally between all primary surgeons.  If billed charge is less than the maximum allowable, reimbursement will be at billed charge.

-63

Procedure Performed on Infants less than 4kg

Modifier -63 is intended to describe a significant increase in physician work and complexity related to invasive surgery on neonates and infants up to a present body weight of 4 kg. There is more work and complexity due to temperature control, obtaining IV access, maintenance of hemostasis, etc

Both modifier -63 and -22 will not be valid for the same procedure code(s).

After appropriate use of modifier is validated, reimbursement will be at an additional 20% of the allowable.

-66

Surgical Team

When appropriate and more than two surgeons of different specialties perform different procedures (identified by different procedure codes), reimburse at billed charges or the maximum allowable, whichever is less for each procedure. Multiple procedure guidelines will apply for multiple procedures by the same surgeon.

-73

Discontinued
Out-Patient Procedure Prior to Anesthesia Administration

Reimbursement will be billed charges or 50% of allowable, whichever is less.

-74

Discontinued
Out-Patient Procedure After Anesthesia Administration

Reimbursement will be billed charges or 100% of allowable, whichever is less.

-76

Repeat Procedure by Same Physician

The use of the modifier is to indicate a procedure or service was repeated subsequent to the original procedure or service.  This indicates that the repeat procedure is not a duplicate claim.

-78

Return to the Operating Room for a Related Procedure During the Postoperative Period

Reimbursement will be based on the allowable utilizing the CMS assigned intra-operative component for the CPT code billed or billed charges, whichever is less.

-79

Unrelated Procedure or Service by the Same Physician during the Postoperative Period

-80

Assistant Surgeon

CMS designates procedure codes eligible for reimbursement for an assistant at surgery.  Regence BlueShield of Idaho reimburses assistant at surgery based on the CMS list of procedure codes. Provider Specialties eligible for reimbursement for codes with modifier –80 include MD, DO and DPM.

For Commercial products only: When the procedure submitted is defined as eligible for an assistant, it is reimbursed at billed charges or 20% of allowable, whichever is less.

-81

Minimum Assistant Surgeon

CMS designates procedure codes eligible for reimbursement for an assistant at surgery.  Regence BlueShield of Idaho reimburses assistant at surgery based on the CMS list of procedure codes.  Provider Specialties eligible for modifier –81 include MD, DO and DPM. This modifier is not intended for use by non-physician assistants (e.g., RN, PA).

For Commercial products only: When the procedure submitted is defined as eligible for an assistant and the assistant surgeon is a physician, it is reimbursed at billed charges or 10% of allowable, whichever is less.

-82

Assistant Surgeon (when qualified resident surgeon not available)

CMS designates procedure codes eligible for reimbursement for an assistant at surgery.  Regence BlueShield of Idaho reimburses assistant at surgery based on the CMS list of procedure codes.  Provider Specialties eligible for modifier –82 include MD, DO and DPM.

For Commercial products only: When the procedure submitted is defined as eligible for an assistant and the assistant surgeon is a physician, it is reimbursed at billed charges or 20% of allowable, whichever is less.

-91

Repeat Clinical Diagnostic Laboratory Test

Reimbursed at billed charges or the allowable for a single procedure, whichever is less.

-P3

A patient with severe systemic disease

For Commercial products only: Reimbursement for eligible claims will not exceed one (1) unit at billed charge or allowable, whichever is less.

-P4

A patient with severe systemic disease that is a constant threat to life

For Commercial products only: Reimbursement for eligible claims will not exceed two (2) units at billed charge or allowable, whichever is less.

-P5

A moribund patient who is not expected to survive without the operation

For Commercial products only: Reimbursement for eligible claims will not exceed three (3) units at billed charge or allowable, whichever is less.

-AS

P.A., nurse practitioner, or clinical nurse specialist services for assistant surgery

CMS designates procedure codes eligible for reimbursement for an assistant at surgery.  Regence BlueShield of Idaho reimburses assistant at surgery based on the CMS list of procedure codes.  Provider Specialties eligible for modifier – AS include CNS, PA, CRNFA, RNFA, NP, Licensed Professional Nurse, DDS, DMD, and SurgicalTech.  This is subject to provider contract eligibility.

For Commercial products only: When the procedure submitted is defined as eligible for an assistant, it is reimbursed at billed charges or 10% of allowable, whichever is less.

-MS

Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty

Reimbursed per contracted amount or lesser of billed charges or allowable, as appropriate.

-NU

New Equipment

For Commercial products only: Reimbursed per contracted amount or lesser of billed charges or allowable, as appropriate.

-RR

Rental (use the “RR” modifier when DME is to be rented)

For Commercial products only: Reimbursed per contracted amount or lesser of billed charges or allowable, as appropriate.

-SG

Ambulatory surgical Center (ASC) facility service or Surgical Suite service

For Commercial products only: Reimbursed at billed charges or the ASC allowable, whichever is less.  The –SG modifier should be billed in the first position. Additional modifiers should be billed in the subsequent positions.

-TC

Technical Component

CMS publishes the National Physician Fee Schedule. This publication includes which CPT and HCPCS codes are eligible for reimbursement for modifier -TC. In the absence of a CMS professional and/or technical indicator, Regence BlueShield of Idaho may establish a  technical designation. When the procedure code submitted is defined as eligible for modifier –TC, reimbursement will be at billed charges or the technical components associated with the modifier –TC fee schedule whichever is less.

-UE

Used Durable Medical Equipment

For Commercial products only: Reimbursed per contracted amount or lesser of billed charges or allowable, as appropriate.