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ModifierDescriptionCorrect ApplicationImpact OnReimbursementQZCRNA service withoutmedical direction by MDUse to identify CRNA serviceperformed without medicaldirection by physician. (Referto sections 51.02 and 51.03).Refer to section 51.03 forreimbursement policy.RPReplacement and repair(DME)Use when billing for repairs fordurable medical equipment,orthotics, or prosthetics.(Refer to section 10.02).Directs claim for appropriatepricing.RRMonthly DME RentalUse to identify DME rented fora full month. (Refer to Section10.02).Directs claim to DME feeschedule for monthly rentalof durable medicalequipment.RTRight SideUse to indicate a procedurewas performed on right side ofbody.Used for data collection andtracking.SCMedically necessary serviceor supplyUse to identify a medicalsupplies billed by DME supplierthrough DME program. (Referto Section 10.02).Directs the claim to the DMEfee schedule for medicalsupplies.SDServices provided byregistered nurse withspecialized, highly technicalhome infusion trainingUse to identify home infusionnurse services which havebeen prior authorized by DOM.Directs claim to correctpricing for home infusionnurse services.TALeft foot, great toeUse to indicate a procedurewas performed on the great toeof the left foot.Used for data collection andtracking.TCTechnical ComponentUse to identify the technicalcomponent of a procedure isbeing reported separately.Directs claim to feeschedule for technicalcomponents.TFMYPAC Waiver: StatutorilyExcludedndUse in the 2 modifier field forrespite days 10 through 19 (orless) provided in a PRTF(Code H0045)Days 10 through 19 will bepaid at the MYPACprovider’s per diem rate.ID/DD Waiver: Immediatelevel of careUse in 2nd modifier field whenbilling T2022 SupportCoordination 2nd level paymentfor ID/DD Waiver.Directs claim to correctpricing file.9

ModifierTGTHDescriptionComplex High Level of CareOB treatment/ services,prenatal/ postpartumCorrect ApplicationImpact onReimbursementUse in the 2nd modifier field forrespite days 4 through 14 (orless) provided in an acutepsychiatric hospital (CodeH0045) when used for MYPACWaiver services.Days 4 through 14 will bepaid at the MYPACprovider’s per diem rate.EPSDT- Use to report RN orL.P.N Private Duty Nursing(PDN) services provided toMississippi Medicaidbeneficiary on homeventilation.Directs claim to pricing filefor PDN for ventilationpatients.Use to identify all maternityservices. (Refer to Sections38.05 and 51.05).Used to bypass physicianvisit limitation of twelve (12)visits per fiscal year and fordata collection and tracking.Use to identify physicianservices for normal well-baby.(Bill on baby’s own Medicaid IDnumber with appropriate CPTcode and modifier –TH)Used for data collection andtracking and to bypass TANrequirement on physicianclaim for normal (well baby)newborn.TLEarly Intervention IFSPUse with code T1017 toidentify Early Interventiontargeted case management.Directs claim to pricing filefor this Early Interventionservice.T1Left foot, second digitUse to indicate a procedurewas performed on the seconddigit of the left foot.Used for data collection andtracking.T2Left foot, third digitUse to indicate a procedurewas performed on the thirddigit of the left foot.Used for data collection andtracking.T3Left foot, fourth digitUse to indicate a procedurewas performed on the fourthdigit of the left foot.Used for data collection andtracking.T4Left foot, fifth digitUse to indicate a procedurewas performed on the fifth digitof the left foot.Used for data collection andtracking.10

ModifierDescriptionCorrect ApplicationImpact onReimbursementT5Right foot, Great toeUse to indicate a procedurewas performed on the great toeof the right foot.Used for data collection andtracking.T6Right foot, second digitUse to indicate a procedurewas performed on the seconddigit of the right foot.Used for data collection andtracking.T7Right foot, third digitUse to indicate a procedurewas performed on the thirddigit of the right foot.Used for data collection andtracking.T8Right foot, fourth digitUse to indicate a procedurewas performed on the fourthdigit of the right foot.Used for data collection andtracking.T9Right foot, fifth digitUse to indicate a procedurewas performed on the fifth digitof the right foot.Used for data collection andtracking.U1HCBS/Elderly & DisabledWaiver.Use in 1st modifier field toidentify all HCBS/Elderly &Disabled Waiver services.(Refer to Section 65.11).Refer to Section 65.11forreimbursement policy.U2HCBS/Independent LivingWaiver.Use in 1st modifier field toidentify all HCBS/IndependentLiving Waiver services. (Referto Section 66.10).Used for reporting purposesfor the correct collection ofmatch from the MississippiDepartment of RehabilitationServices.Refer to Section 66.10 forreimbursement policy.U3HCBS/ IntellectualDisabilities/DevelopmentalDisabilities WaiverUse in 1st modifier field toidentify all HCBS/ IntellectualDisabilities/DevelopmentalDisabilities Waiver services.11Used for reporting purposesfor the correct collection ofmatch from the Departmentof Mental Health.

ModifierDescriptionCorrect ApplicationImpact OnReimbursementU4HCBS/Assisted LivingWaiver.Use in 1st modifier field toidentify all HCBS/AssistedLiving Waiver services. (Referto section 68.10).Refer to Section 68.10 forreimbursement policy.U5HCBS/Traumatic BrainInjury/Spinal Cord InjuryWaiver.Use in 1st modifier field toidentify all HCBS/TraumaticBrain Injury/Spinal Cord InjuryWaiver services. (Refer toSection 69.10).Used for reporting purposesfor the correct collection ofmatch from the MississippiDepartment of rehabilitationServices.Refer to Section 69.10 forreimbursement policy.UEUsed Durable MedicalEquipmentUse to report purchase of useddurable medical equipment.Refer to section 10.02.12Directs claim to DME feeschedule for purchase ofdurable medical equipment.

Table CAmbulance HCPCS ModifiersCorrect ApplicationImpact onReimbursementModifierDescriptionDDiagnostic or therapeutic otherthan the physician’s office orhospital when these codes areused as origin codes.Use to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.EResidential, domiciliary,custodial facilityUse to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.GHospital based dialysis facility(hospital or hospital-related)Use to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.HHospitalUse to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.ISite of transfer (e.g, airport orhelicopter pad) between typesof ambulancesUse to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.JNon-hospital based dialysisfacilityUse to identify the place oforigin or destination duringan ambulance transport.(Refer to section 8.12).Used for data collectionand tracking.NSkilled nursing facilityUse to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.PPhysician’s office (includeshealth maintenanceorganization, ASC hospitalfacility, clinic, etc.)Use to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.13

ModifierDescriptionCorrect ApplicationImpact onReimbursementRResidenceUse to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.SScene of accident or acuteeventUse to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.X(Destination code only)Intermediate stop atphysician’s office on the wayto the hospital (includes healthmaintenance organization,ASC, hospital facility, clinic,etc.)Use to identify the place oforigin or destination duringan ambulance transport.(Refer to Section 8.12).Used for data collectionand tracking.14

Division of MedicaidState of MississippiProvider Policy ManualNew:XRevised: XCurrent:Section: General CodingInformationSection: 81.02Pages:14Cross Reference: Ambulance 8.0Durable Medical Equipment 10.0;Community Mental Health Centers 15.0;Community-Based Mental Health Services 21.0;Maternity 38.0;Radiology 46.0;Anesthesia 51.0;Surgery 52.0;Physician 55.0;HCBS/Elderly & Disabled Waiver 65.0;HCBS/Independent Living Waiver 66.0;HCBS//Mentally Retarded Developmentally DisabledWaiver 67.0; HCBS/ Intellectual Disabilities/Developmental Disabilities Waiver 16.0HCBS/Assisted Living Waiver 68.0;HCBS/Traumatic Brain Injury/Spinal Cord InjuryWaiver 69.0;Subject: ModifiersEffective Date:01/01/0803/01/11A modifier is a numeric or alphanumeric character that is reported with Healthcare Common ProcedureCoding System (HCPCS) codes, when appropriate. Modifiers provide payer sources with additionalinformation for a claim. A modifier provides the means by which a provider can report a service orprocedure was altered by some specific circumstance. Use of a modifier does not change the definitionof the code. While modifiers are valuable in the reporting of services, uses of modifiers do not guaranteereimbursement.Modifiers are applicable nationally for Medicare, Medicaid, and other insurance carriers. The Division ofMedicaid (DOM) accepts all modifiers in accordance with HIPPA standards; however, DOM only requiresand utilizes certain modifiers to guide reimbursement or to capture data. On the subsequent pages,Tables A, B, and C identify those utilized by DOM.There are two levels of modifiers within the HCPCS coding system. Level I or CPT modifiers are 2 digit numeric or alphanumeric characters developed by theAmerican Medical Association (AMA). Refer to Table A for a listing of Level I modifiers that areutilized by DOM. Level II or HCPCS modifiers are 2 digit alpha or alphanumeric characters developed by theCenters for Medicare and Medicaid Services (CMS) as an adjunct coding system to the AMACurrent Procedural Terminology (CPT) code sets. Refer to Table B for a listing of Level IImodifiers that are utilized by DOM.DOM also requires that ambulance providers use ambulance HCPCS modifiers to report the pickup originand destination location. Refer to Table C for a listing of Level II Ambulance HCPCS modifiers that areutilized by the Mississippi Medicaid Program.Some common reasons for using modifiers include, but are not limited to, the following: A service or procedure had a professional and technical component.A procedure(s) was performed by multiple physicians (Ex: assistant surgeon, co-surgeon, teamsurgeon).Only part of a service was performed.A bilateral procedure was performed.Multiple surgical procedures were performed.Identification of a specific site.15

To identify whether equipment being purchased or rented.Origin/destination for ambulance servicesDocumentation RequirementsCareful documentation in medical records is essential in supporting coding with modifiers. Medicalrecords must be complete and describe the modified or altered circumstances which justify use of amodifier with a code. Providers utilizing modifiers on claims should be knowledgeable of the correctusage, the documentation requirements, and DOM policies relating to use of modifiers. Providers shouldreview each claim carefully prior to submission to ensure that documentation, if requested, can supportuse of the modifiers. In addition, all DOM documentation policies throughout the Provider Policy Manualmay also apply to use of modifiers.16

Table ALevel I (CPT) ModifiersImpact OnReimbursementModifierDescriptionCorrect Application26Professional ComponentUse to identify the professionalcomponent of a physician servicewhich is being reported separately.Directs claim to feeschedule for professionalcomponents.50Bilateral ProcedureUse to report exact procedures thatare performed at the sameoperative session by the samephysician on anatomically bilateralsides of the body identified by thesame CPT code. (Refer to Section52.04).Refer to Section 52.04 forreimbursement policy.51Multiple ProceduresUse to identify secondarysurgeries. (Refer to appropriatepolicies in Sections 52.02 through52.11).Refer to Section 52.03 forreimbursement policy.54Surgical Care onlyUse when one physician performsa surgical procedure and anotherprovides preoperative and/orpostoperative management.(Refer to Section 52.13).Refer to Section 52.13 forreimbursement policy.55PostoperativeManagementUse when one physician performedthe postoperative managementand another physician performedthe surgical procedure. (Refer toSection 52.13).Refer to Section 52.13 forreimbursement policy.56PreoperativeManagementUse when one physician performedthe preoperative care andevaluation and anotherphysician/practitioner performedthe surgical procedure. (Refer toSection 52.13).Refer to Section 52.13 forreimbursement policy.Use when two surgeons (usuallydifferent specialties) work togetheras primary surgeons performingdistinct parts(s) of a singleprocedure simultaneously. (Referto Sections 52.08).Refer to Section 52.08 forreimbursement policy.62Two Surgeons (Cosurgery)17Surgical codes billed withmodifier 56 will be denied.

ModifierDescriptionCorrect ApplicationImpact OnReimbursement66Surgical TeamUse when a team of surgeons(more than two (2) surgeons ofdifferent specialties) are required toperform specifically differentprocedures simultaneously. (Referto Section 52.09).Refer to Section 52.09 forreimbursement policy.80Assistant SurgeonUse when a licensed physicianactively assists the physician incharge of a case in performing asurgical procedure. (Refer toSection 52.07).Refer to Section 52.07 forreimbursement policy.18

Table BLevel II (HCPCS) ModifiersCorrect ApplicationImpact OnReimbursementModifierDescriptionAAAnesthesia performed byanesthesiologistUse to identify that service waspersonally performed byanesthesiologist. (Refer toSection 51.02)Directs claim to allow 100%of the Medicaid allowancefor the physician service.AHClinical PsychologistUse in 2nd modifier field toidentify services performed bya clinical psychologist forCommunity-Based MentalHealth Services. (Refer toSection 21.02).Used for data collection andtracking.AJClinical Social WorkerUse in 2nd modifier field toidentify services performed bya clinical social worker forCommunity-Based MentalHealth Services. (Refer toSection 21.02).Used for data collection andtracking.EPEarly and PeriodicScreening, Diagnostic, andTreatment Program (EPSDT)servicesUse with all Mississippi CoolKids Program (EPSDT)Screening codes.Used for data collection andtracking.Use on all codes billed by aschool provider.Used to direct claim topricing file for services by aschool provider.Use on codes for private dutynursing (PDN) services exceptfor PDN services beneficiarieson home ventilator (Refer tomodifier TG).PHRM/ISS providers must usewhen billing for infant in-homenurse services.Used for data collection andtracking.Vaccines for Children Programproviders must use whenbilling either a vaccine code(s)and/or administration code(s).Vaccine codes: Used fordata collection and tracking.19Directs claims forappropriate pricing.Administration codes:Directs claim to VFC feeschedule for pricingadministration of vaccines.

ModifierDescriptionCorrect ApplicationImpact OnReimbursementFPServices part of FamilyPlanning ProgramUse to identify all familyplanning services in both thenon-waiver and waiverprograms.Used for data collection andtracking.GCThis service has beenperformed in part by aresident under the directionof a teaching physician.Use to identify that theanesthesiologist assumed fullresponsibility for the patientwhile the anesthesia was beingadministered by a resident in ateaching facility. (Refer toSections 51.02 and 51.04).Used for data collection andtracking.GKMYPAC Waiver: StatutorilyExcluded: Acute respiteservicesUse in the 2nd modifier field forrespite days 1 through 3 (orless) or respite days 15through 29 provided in anacute psychiatric hospital(Code H0045).Days 1 through 3 and days15 through 29 will be zeropaid.GTVia interactive audio andvideo telecommunicationsystemsUse to identify teleradiologyservices. (Refer to Section46.06).Used for data collection andtracking.GYMYPAC Waiver: StatutorilyExcludedUse in the 2nd modifier field forrespite days 1 through 9 (orless) or respite days 20through 29 (or less) provided ina PRTF (Code H0045).Days 1 through 9 and days20 through 29 will be zeropaid.HAChild/Adolescent ProgramUse in 2nd modifier field to billcertain services provided byCommunity Mental HealthCenters (Refer to Section15.30).Used for data collection andtracking.Use in the 1st modifier field toidentify expanded EPSDTMental Health Services forCommunity Based MentalHealth Services. (Refer tosection 21.0).20

ModifierDescriptionCorrect ApplicationImpact OnReimbursementHBAdult program, non-geriatricUse in the 2nd modifier field tobill certain services provided byCommunity Mental HealthCenter (Refer to section15.30).Used for data collection andtracking.HCAdult program, geriatricUse in the 2nd modifier field tobill certain services provided byCommunity Mental HealthCenters (Refer to Section15.30).Used for data collection andtracking.HELevel II for MI (CommunityMental Health Center)Directs claims forappropriate pricing.HILevel II for MR (RegionalCenter)Use when Level II PASRREvaluation for Mental illness(MI) is conducted by aCommunity Mental HealthCenter.Use when Level II PASRREvaluation for MentalRetardation (MR) is conductedby a Regional Center.HKMYPAC Waiver: Special HighRisk Mental HealthPopulationUse in 1st modifier field for allMYPAC waiver services(Codes T2022, H2022, orH0045) provided by a MYPACprovider.Directs claim to feeschedule for pricing ofMYPAC Waiver services.HNBachelor

A procedure(s) was performed by multiple physicians (Ex: assistant surgeon, co-surgeon, team surgeon). Only part of a service was performed. A bilateral procedure was performed. Multiple surgical procedures were performed. Identification of a specific site. To identify whether equipment being purchased or rented.