Pricing Modifiers , continued

26 (Professional Component)

Certain procedures are a combination of a professional component and a technical component.

For professional services rendered in the hospital, outpatient hospital, emergency room, or ambulatory surgery center, the practitioner may bill only the professional component.

Use modifier 26 to separately report the professional component. If the same provider renders both the professional component and the technical

component service, do not bill the professional and technical components separately.

50 (Bilateral Procedure)

Use modifier 50 to identify bilateral procedures that are performed during the same operative session.

The procedure code along with modifier 50 should be identified on one claim line.

If bilateral pricing rules apply to a procedure, bill the procedure code on one claim line with modifier 50, do not bill on separate lines with LT (left) and RT (right).

Modifier 50 reimburses 150 percent of the allowable reimbursement for a procedure code or suspends for multiple surgery pricing, if applicable.

Do not use modifier 50 if the CPT definition identifies the service solely as a bilateral procedure or as a “unilateral or bilateral” procedure in the descriptor.

The quantity, or number of units, to be entered on the same claim line as a bilateral procedure is 1 (one).

51 (Multiple Procedures)

Use modifier 51 when multiple surgeries are performed on the same recipient, same date of service. Payment for these procedures is as follows:

• 100 percent of highest reimbursed CPT code;

• 50 percent of second highest reimbursed CPT code; and

• 25 percent of all others.

Do not append modifier 51 to add-on codes.

52 (Reduced Services)

Use modifier 52 when under certain circumstances, a service or procedure is partially reduced at the practitioner’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced.

Reimbursement rate is 50 percent of the allowable fee for the procedure code.

Pricing Modifiers

53 (Discontinued Services)

Use modifier 53 under circumstances when the practitioner elects to terminate a surgical or diagnostic procedure. Due to extenuating

circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure.

Reimbursement rate is 25 percent of the allowable fee for the procedure code.

54 (Surgical Care Only)

Use Modifier 54 to indicate that the practitioner performed surgical care only, and another practitioner managed the preoperative or postoperative care.

Reimbursement rate is 50 percent of the maximum allowable fee for the procedure code.

55 (Postoperative Management Only)

Use modifier 55 to identify post-operative care only. When one practitioner performs the postoperative management and another practitioner has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55.

Reimbursement rate is 30 percent of the maximum allowable fee for the procedure code.

56 (Preoperative Management Only)

Use modifier 56 to indicate preoperative care only. When one practitioner performs the preoperative care and evaluation and another practitioner performs the surgical procedure, the preoperative component may be identified by adding the modifier 56.

Reimbursement rate is 20 percent of the maximum allowable fee for the procedure code.

62 (Two Surgeons) Use modifier 62 to indicate that two practitioners worked together as primary surgeons performing distinct parts of a single reportable procedure. When the same procedure code is used, both practitioners must use modifier 62.

If both practitioners do not report the modifier 62, this can result in one practitioner being reimbursed at 100 percent and the other physician’s claim being denied as a duplicate claim.

Medicaid reimburses each practitioner 60% of the allowable fee for the procedure code.

Pricing Modifiers

62 (Two Surgeons) If the practitioner performs additional procedures during the same operative session without a co-surgeon, report those procedures without the modifier.

If one of the co-practitioners acts as an assistant in the performance of any additional procedures during the same operative session, report the procedure separately with modifier 80.

66 (Surgical Team) Use modifier 66 to indicate a complex procedure requiring the skill of several practitioners of the same or different specialties.

Medicaid reimburses a maximum of three practitioners at 100% of the maximum allowable fee for procedures requiring a surgical team.

The practitioner must submit documentation with the claim to receive surgical team reimbursement.

Currently, this modifier is limited to practitioners performing organ transplants.

80 (Assistant Surgeon)

Use modifier 80 to identify procedures that require medically necessary surgical assistant services.

Only one assistant surgeon may be reimbursed for each operative session.

For physician providers, modifier 80 reimburses 16 percent of the maximum fee for the procedure code.

Multiple surgical procedures are reimbursed as follows:

• 16 percent of 100 percent of the maximum allowable fee for primary surgical procedure (first claim line);

• 16 percent of 50 percent of the maximum allowable fee for the second surgical procedure; and

• 16 percent of 25 percent of the maximum allowable fee for all other surgical procedures.

ARNPs, PAs, and RNFAs are reimbursed at 80 percent of the physician’s assistant surgeon rate, which is 16% of the maximum fee. So that the rate for ARNPs, PAs, and RNFAs is 12.8% of the maximum fee.

QK (Physician Supervision of Anesthesia Performed by a CRNA)

Use modifier QK when an anesthesiologist supervises the concurrent

anesthesia services performed by two, three, or four certified registered nurse anesthetists (CRNA.

These services reimburse 20 percent of the anesthesia fee allowed for that procedure.

Pricing Modifiers

TC (Technical Component)

Certain procedures are a combination of a professional component and a technical component.

Procedure codes reimbursable with a technical component are radiology procedure codes (70000-79999) in the practitioner office setting only.

A separate TC modifier for other procedure codes is only reimbursable for Medicare cross-over claims.

Use modifier TC when the radiological technical component is reported separately. Acceptable procedure codes billable for technical component are identified in the “TC” column in the radiology fee schedule. Do not bill the technical component separately, if the same provider performs both the technical and professional components.