Provider Payment Guidelines

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Modifiers

Policy
Mass General Brigham Health Plan accepts industry standard modifiers to enable increased accuracy in
recording patient encounters. A modifier provides the means by which a provider can report that a
service rendered and articulated by a service code has been altered by one or more specific
circumstances.

Mass General Brigham Health Plan accepts all standard CPT and HCPCS modifiers in accordance with the
appropriate CPT or HCPCS procedure code(s). Certain modifiers, when submitted appropriately, will
impact compensation. The absence of an appropriate modifier, or the use of an inappropriate modifier,
may result in claim denial.

Reimbursement
Providers are reimbursed according to the plan’s network provider reimbursement or contracted rates.
Claims are subject to payment edits that are updated at regular intervals.

Covered services are defined by the member’s benefit plan. The manner in which covered services are
reimbursed is determined by the Mass General Brigham Health Plan Payment Policy and by the
provider’s agreement with Mass General Brigham Health Plan. Member liability amounts may include,
but are not limited to, copayments, deductible, and/or co-insurance, and will be applied dependent
upon the member’s benefit plan.

Various services and procedures require referral and/or authorization. Referral and authorization
requirements can be located here.

Please reference procedure codes from the current CPT, HCPCS Level II, and ICD-10-CM manuals, as
recommended by the American Medical Association (AMA), the Centers for Medicare & Medicaid
Services (CMS), and the American Hospital Association. CMS and the AMA revise HIPAA medical codes
on a pre-determined basis, including changes to CPT, HCPCS, and ICD-10 codes and definitions.

Please refer to the CMS or CPT guidelines for requisite modifier usage when reporting services. The

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absence or presence of a modifier may result in differential claim payment or denial.

Mass General Brigham Health Plan reviews claims to determine eligibility for payment. Services
considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global
allowance, are not eligible for separate reimbursement. Please refer to Coding Provider Payment
Guidelines for more information.

All claims are subject to audit services and medical records may be requested from the provider.

Modifier Tables
The following tables are intended to provide guidance for the proper use of modifiers, and for potential
reimbursement impact. Please refer to the AMA CPT and HCPCS manuals for specific guidelines on
required and appropriate modifier use.

Ambulance
Report using two modifiers; origin and destination

Modifier Descriptor
D Diagnostic/therapeutic site other than “P” or “H”
Residential, domiciliary, custodial facility (nursing home, not skilled
E
nursing facility)
G Hospital-based dialysis facility (hospital or hospital related)
GM Multiple patients on an ambulance trip
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between types of ambulance
J Non-hospital-based dialysis facility
N Skilled nursing facility (SNF)
P Physician’s office (includes HMO nonhospital facility, clinic, etc.)
QM
Ambulance service provided under arrangement by a provider of services
QN
R Residence
S Scene of accident or acute event

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Modifier Descriptor
Intermediate stop at physician’s office en-route to hospital (includes
X
HMO non-hospital, facility, clinic, etc.)

Anatomic
Informational; do not impact reimbursement

Modifier Descriptor
E1-E4 Eyelids
FA, F1-F9 Fingers
TA, T1-T9 Toes
RT Right side of body
LT Left side of body
LC, LD, LM, RC, RI Coronary artery modifiers

Anesthesia

Modifier Descriptor Reimbursement Impact/Comments

• Modifier is informational and does
23 Unusual Anesthesia
not affect reimbursement
Anesthesia service personally • 100% of anesthesia contract
AA
performed by physician allowable
Medical supervision by a
• 3 ASA base units at anesthesia
AD physician for more than 4
contract allowable
concurrent procedures
Medical direction of two, three or
QK four concurrent anesthesia • 50% of contract allowable
procedures involving qualified
individuals
CRNA service with medical
QX • 50% of contract allowable
direction by a physician

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Modifier Descriptor Reimbursement Impact/Comments

Medical direction of one
QY Certified Registered Nurse Anesthetist • 50% of contract allowable
by an Anesthesiologist
CRNA service; without medical
QZ • No impact on reimbursement
direction by a physician

• No additional reimbursement for

anesthesia by a surgeon, assistant
Anesthesia performed by
47 surgeon, nursing staff or any other
surgeon
non-anesthesiologist professional
during a procedure

P1-P6 Physical Status Modifiers • No additional reimbursement

Other

Modifier Descriptor Reimbursement Impact/Comments

• Affects reimbursement for surgical
codes only
• Additional reimbursement
considered if the additional work is
documented in the operative
22 Increased Procedural Services report submitted to support the
use of modifier 22. Cover letters are
not considered part of the medical
record and cannot be used to
support a case for additional
reimbursement
• 120% of fee schedule allowable
after medical record review

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Modifier Descriptor Reimbursement Impact/Comments

• 100% of contract allowable amount only
when the service and diagnosis are not
related to the surgical procedure
Unrelated E/M service by
• May require medical record review
24 same physician during post-
• Visits for complications of surgery that do
op period
not require a return trip to the operating
room are not to be reported with Modifier
24
• Clinical notes must support a significant,
separately identifiable E/M service above
and beyond the services provided
Significant, separately identifiable • For same day preventive and sick E/M,
25 E/M service by same physician on service with lower valued resource
same day of procedure or service consumption will be reimbursed at 50% of
allowable amount.
• All claims submitted with this modifier are
subject to pre and post-pay audit.
• Professional component of allowed
amount
26 Professional Component • Centers for Medicare and Medicaid
designate which procedure codes are valid
for use with modifier 26.

32 Mandated Services • Not reimbursed

• Modifier 33 should be appended to the
listed CPT/HCPCS codes contained in the
33 Preventive Service
U.S. Preventive Services Task Force List
which have a category A or category B
• rating.
150% of contract allowable
50 Bilateral procedure • Not for use with codes whose narrative
indicates bilateral
• 50% of the contract allowable, unless
51 Multiple procedure
otherwise specified.

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Modifier Descriptor Reimbursement Impact/Comments

52 Reduced Services • 50% of contract allowable
53 Discontinued Procedure • 25% of fee schedule allowable
54 Surgical care, only • 75% of fee schedule allowable

• 25% of contract allowable

• Physician performing outpatient post-
operative care should report modifier 55
• Surgeon should not report modifier 55
55 Post-op management, only
• Dates of service should indicate the range
from first date of service to last. The
number of units reported should reflect
the number of services rendered
56 Pre-op management, only • 25% of contract allowable

57 Decision for Surgery • No impact on reimbursement

Staged or Related Procedure or

Service by the Same Physician or
58 Other Qualified Health Care • No impact on reimbursement
Professional During the
Postoperative Period

• Append Modifier 59{X} to identify

59 Distinct procedural service
procedures and/or services that are
distinct and unrelated. Medical record
XE Separate encounter documentation must clearly support the
different session and/or procedure, not
normally performed on the same day by
XS Separate structure
the same physician and/or group.
• Use modifier 59 only when modifier
XP Separate practitioner {XESPU} is not appropriate

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Modifier Descriptor Reimbursement Impact/Comments

• Modifier 59 should be used only in
absence of a more descriptive modifier,
XU Unusual non-overlapping service and does not alter the reimbursement
impact when billed in conjunction with
another modifier
ZB Pfizer/Hospira • Required when HCPCS code Q5102.

ZC Merck/Samsung Bioepis • Required when HCPCS code Q5102

• 62.5% of contract allowable

• Use Modifier 62 only with qualified service
62 Two Surgeons
codes as allowed by the CMS National
Physician Fee Schedule Relative Value File

• 62.5% of contract allowable

• Medical documentation is required
66 Surgical Team • Use Modifier 66 only with qualified
procedures as allowed by the CMS
national Physician Fee Relative Value File

Discontinued Out-Patient
Hospital/Ambulatory Surgery
73 Center (ASC) Procedure Prior to • 50% of contract allowable
the Administration of
Anesthesia
Discontinued Out-Patient
Hospital/Ambulatory Surgery
74 • 50% of contract allowable
Center (ASC) Procedure After
Administration of Anesthesia
• No impact on reimbursement
Repeat procedure by same
76 • For repeat, same day laboratory services,
physician
use modifier 91
• No impact on reimbursement
Repeat procedure by another
77 • For repeat, same day laboratory services,
physician
use modifier 91
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Modifier Descriptor Reimbursement Impact/Comments

Unplanned return to OR for
78 related procedure during post- • 75% of contract allowable
op period
Unrelated procedure or service
79 by same physician during • No impact on reimbursement
postoperative period
• 16% of contract allowable
80 Assistant Surgeon • Valid for services designated in the CMS
National Relative Value File as qualifying
• 16% of contract allowable
81 Minimum Assistant Surgeon • Valid for services designated in the CMS
National Relative Value File as qualifying
Assistant Surgeon (when • 16% of contract allowable
82 qualified resident surgeon not • Valid for services designated in the CMS
available) National Relative Value File as qualifying
90 Reference laboratory • No impact on reimbursement
Repeat clinical diagnostic • No impact on reimbursement
91
laboratory test • Services must meet medical necessity
criteria
92 Alternative laboratory testing • No impact on reimbursement
Synchronous telemedicine
Service rendered via a real- • Reimbursement is calculated using 50% of
95 time interactive audio and the Practice Expense Relative Value Unit
video telecommunications (RVU) for the service
system
96 Habilitative Services • No impact on reimbursement
97 Rehabilitative Services • No impact on reimbursement
99 Multiple modifiers • No impact on reimbursement

Physician billing for PA under

AM • No impact on reimbursement
direct supervision

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Modifier Descriptor Reimbursement Impact/Comments

Physician assistant, nurse
practitioner, or
AS • 16% of contract allowable
clinical nurse specialist as
assistant-at- surgery
Outpatient occupational therapy
CO services furnished in whole or in part • No impact on reimbursement
by an occupational therapy assistant

Outpatient physical therapy services

CQ furnished in whole or in part by a • No impact on reimbursement
physical therapist assistant
Modifier ER is primarily a billing
modifier to help identify items and
ER services furnished by an off-campus, • No impact on reimbursement
provider-based emergency
department
Telehealth services for diagnosis,
G0 evaluation, or treatment, of • No impact on reimbursement
symptoms of an acute stroke
• Reimbursement is calculated using 50% of
Via interactive audio and video
GT the Practice Expense Relative Value Unit
telecommunications system
(RVU) for the service
Multiple patients on one ambulance
GM • 50% of contract allowable
trip

Medical direction of 2, 3, or 4
QK concurrent anesthesia procedures • 50% of contract allowable
involving qualified individuals

CRNA service with medical direction

QX • 50% of contract allowable
by a Physician

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Modifier Descriptor Reimbursement Impact/Comments

Medical direction of one Certified
QY Registered Nurse Anesthetist by an • 50% of contract allowable
Anesthesiologist

• No reimbursement
• Append to Vaccine code
SL State Supplied Vaccine
• Must be appended to state-supplied
vaccine codes

Developmental Testing services: append to CPT 96110.

Modifier Descriptor
Medicaid Level of Care: Completed behavioral health screening using a standardized
behavioral health screening tool with no behavioral health need identified when
U1
administered by a physician, independent nurse midwife or independent nurse
practitioner.
Medicaid Level of Care: Completed behavioral health screening using a standardized
behavioral health screening tool and a behavioral health need was identified when
U2
administered by a physician, independent nurse midwife or independent nurse
practitioner.
Medicaid Level of Care: Completed behavioral health screening using a standardized
U3 behavioral health screening tool with no behavioral health need identified when
administered by a nurse midwife employed by a physician.
Medicaid Level of Care: Completed behavioral health screening using a standardized
U4 behavioral health screening tool and a behavioral health need was identified when
administered by a nurse midwife employed by a physician.
Medicaid Level of Care: Completed behavioral health screening using a standardized
U5 behavioral health screening tool with no behavioral health need identified when
administered by a nurse practitioner employed by a physician.
Medicaid Level of Care: Completed behavioral health screening using a standardized
U6 behavioral health screening tool and behavioral health need was identified when
administered by a nurse midwife employed by a physician.

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Modifier Descriptor
Medicaid Level of Care: Completed behavioral health screening using a standardized
U7 behavioral health screening tool with no behavioral health need identified when
administered by a physician assistant employed by a physician.
Medicaid Level of Care: Completed behavioral health screening using a standardized
U8 behavioral health screening tool and behavioral health need was identified when
administered by a physician assistant employed by a physician.
Medicaid Level of Care: Completed behavioral health screening for the
UD administration and scoring of the Edinburgh Postnatal Depression Scale. UD must be
used together with one of the above modifiers, U1–U8.

Durable Medical Equipment

Modifier Descriptor
KH • Use for first month rental of capped rental items
KI • Use for 2nd and 3rd month rental of capped rental items
KJ • Use for months 4 to 13 for rental of capped rental items
• Rental item, partial month
KR • Bill (1) unit = (1) day rental
• Billed charges must reflect daily charge
• 6 months maintenance/servicing fee, reasonably necessary parts and
MS labor which are not covered under any manufacturer or supplier
warranty
NU • New Equipment
RR • Rental Item

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Early Intervention Services

Modifier Descriptor
AH • Clinical Psychologist
AJ • Clinical Social Worker
GN • Services delivered under an outpatient speech pathology plan of care
GO • Services delivered under an outpatient occupational therapy plan of care
GP • Services delivered under an outpatient physical therapy plan of care
HN • Bachelor’s degree level
TD • RN
TJ • Program group, child and/or adolescent

Serious Reportable Events

The following modifiers are required to be appended when reporting Serious Reportable Events (SRE).
Please also refer to the Serious Reportable Events & Provider Preventable Conditions Provider Payment
Guideline at Serious Reportable Events.

Modifier Descriptor

PA • Surgical or other invasive procedure on wrong body part

PB • Surgical or other invasive procedure on wrong patient
PC • Wrong surgery or other invasive procedure on patient

Related Documents
Ambulance
Anesthesia
DME
Early Intensive Behavioral Intervention Services
Evaluation and Management Services
General Coding and Billing
Serious Reportable Events
Vaccines and Immunizations
Authorization and Referral Guidelines
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Publication History
Topic: Modifiers Owner: Network Management

July 24, 2009 Original documentation

May 17, 2011 Modifiers added, genetic testing code comments, references and disclaimer
updated
August 22, 2011 Added AI Modifier
February 1, 2013 Added AD Modifier
February 1, 2014 Template update; new format; addition of KR, GD, GH modifiers
July 15, 2017 Template update; rearrangement of modifier tables; addition of information on
modifiers GT and 95
May 1, 2018 Document review; template update
January 1, 2019 Document restructure; Modifiers descriptor and references updated
July 1, 2019 QZ Modifier updated and adding modifiers U5-U8 and UD for CPT 96110
January 1, 2023 Document rebrand

This document is designed for informational purposes only. Claims payment is subject to member eligibility and benefits on the
date of service, coordination of benefits, referral/authorization/notification and utilization management guidelines when
applicable, adherence to plan policies and procedures, claims editing logic, and provider contractual agreement. In the event of
a conflict between this payment guideline and the provider’s agreement, the terms and conditions of the provider’s agreement
shall prevail. Payment policies are intended to assist providers in obtaining Mass General Brigham Health Plan’s payment
information. Payment policy determines the rationale by which a submitted claim for service is processed and paid. Payment
policy formulation takes into consideration a variety of factors including: the terms of the participating providers ‘contract(s);
scope of benefits included in a given member’s benefit plan; clinical rationale, industry-standard procedure code edits, and
industry-standard coding conventions.

Mass General Brigham Health Plan includes Mass General Brigham Health Plan, Inc., and Mass General
Brigham Health Plan Insurance Company.

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