WIXLIB

modif app1Modifiers: Approved ListPage updated: August 2020Below is a list of approved modifier codes for use in billing Medi-Cal. Modifiers not listed inthis section are unacceptable for billing Medi-Cal.Modifier OverviewSome modifier information in this section is taken from the CPT code book (CurrentProcedural Terminology code book) and HCPCS code book (Healthcare CommonProcedure Coding System, Level II)Discontinued ModifiersMedicaid programs have traditionally tailored modifiers for their state’s needs. These interim(or local) modifiers are being phased out under HIPAA requirements. Refer to the list ofdiscontinued and invalid modifiers at the end of this section.National Correct Coding InitiativeMedi-Cal claims are subject to a set of claims processing edits that are federally mandated.The edits, controlled by the Centers for Medicare & Medicaid Services (CMS), are part of theNational Correct Coding Initiative (NCCI).Modifiers relevant to the NCCI edit methodology are designated “NCCI associated” in thefollowing modifier list. See the Correct Coding Initiative: National section for how NCCIaffects reimbursement.Note: NCCI does not allow more than one NCCI-associated modifier on a line for TreatmentAuthorization Requests (TARs), CMS-1500 claims and UB-04 claims. TARs andclaims containing two or more NCCI-associated modifiers on the same line will bedenied. In addition, placement of modifiers on the claim is important. AnNCCI-associated modifier should not appear in the first modifier position (next to theprocedure code) unless it is the only modifier on that claim line.Part 2 – Modifiers: Approved List

modif app2Page updated: August 2020‹‹Table of Approved Modifiers››ApprovedModifierNational Modifier DescriptionProgram-Specific Use of the Modifierand Special Considerations22*Increased procedural servicesMay be used with computedtomography (CT) codes whenadditional slices are required or a moredetailed evaluation is necessary.Used by Local Educational Agency(LEA) to denote an additional 15minute service increment renderedbeyond the required initial service time.See Local Educational Agency (LEA) inthe appropriate Part 2 manual for moreinformation.Surgical: May be billed whenprocedures involve significantlyincreased operative complexity and/ortime in a significantly altered surgicalfield resulting from the effects of priorsurgery, marked scarring, adhesions,inflammation, or distorted anatomy,irradiation, infection, very low weight(for example, neonates and smallinfants less than 10 kg) and/or trauma(as documented in a recipient’s medicalrecord). Justification is required on theclaim.Anesthesia: Prone position, base unitsless than or equal to three units.24*NCCIassociatedUnrelated E&M service by thesame physician or other qualifiedhealth care professional during apostoperative periodN/A25*NCCIassociatedSignificant, separately identifiableE&M service by the samephysician or other qualified healthcare professional on the sameday of the procedure or otherserviceN/APart 2 – Modifiers: Approved List

modif app3Page updated: August 2020‹‹Table of Approved Modifiers (continued)››ApprovedModifierNational Modifier DescriptionProgram-Specific Use of the Modifierand Special Considerations26*Professional componentN/A27*NCCIassociatedIncreased procedural servicesN/A33*Preventive serviceClaims billed using modifier 33 are notsubject to specific ICD-10-CM inclusionand/or exclusion criteria. Use ofmodifier 33 indicates the service wasprovided in accordance with a U.S.Preventive Services Task Force A or Brecommendation.47*Anesthesia by surgeonDo not use as a modifier for anesthesiacodes.50*Bilateral procedureN/A51*Multiple proceduresN/A52*Reduced servicesSurgical: For use with surgery codes66820 thru 66821, 66830, 66840, 66850,66920, 66930, 66940 and 66982 thru66985. Requires “By Report”documentation.Used by LEA to denote an annual reassessment. See Local EducationalAgency (LEA) in the appropriate Part 2manual for more information. LEAdoes not require “By Report”documentation.53*Discontinued procedureRequires “By Report” documentation.54*Surgical care onlyN/A55*Postoperative management onlyN/APart 2 – Modifiers: Approved List

modif app4Page updated: August 2020‹‹Table of Approved Modifiers (continued)››ApprovedModifierNational Modifier DescriptionProgram-Specific Use of the Modifierand Special Considerations57†Decision for surgery (majorsurgery only, day before or day ofprocedure)N/A58*NCCIassociatedStaged or related procedure orservice by the same physicianduring the postoperative periodMay be used with codes 15002 thru15429 and 52601 to addresssubsequent part(s) of a stagedprocedure.59*NCCIassociatedDistinct procedural serviceUsed primarily with codes36818 thru 36819 and 76816. Alsoused with other codes, as appropriate,for NCCI purposes.62*Two surgeonsN/A66*Surgical teamN/A73Discontinued outpatienthospital/ambulatory surgerycenter (ASC) procedure prior tothe administration of anesthesia(to be reported by hospitaloutpatient department or surgicalclinic, only)To be reported by hospital outpatientdepartment or surgical clinic only.Requires “By Report” documentation.74Discontinued outpatienthospital/ambulatory surgerycenter (ASC) procedure afteradministration of anesthesiaTo be reported by hospital outpatientdepartment or surgical clinic only.Requires “By Report” documentation.76*Repeat procedure or service bysame physicianN/A77*Repeat procedure by anotherphysicianN/A78*NCCIassociatedUnplanned return to theoperating/procedure room by thesame physician following initialprocedure for a related procedureduring the postoperative periodN/APart 2 – Modifiers: Approved List

modif app5Page updated: August 2020‹‹Table of Approved Modifiers (continued)››ApprovedModifierNational Modifier DescriptionProgram-Specific Use of the Modifierand Special Considerations79*NCCIassociatedUnrelated procedure or service bythe same physician during thepostoperative periodN/A80*Assistant surgeonN/A90*Reference (outside) laboratoryOnly specified providers may use thismodifier.91*NCCIassociatedRepeat clinical diagnosticlaboratory testN/A95Synchronous telemedicineservice rendered via a real-timeinteractive audio and videotelecommunications systemN/A99*Multiple modifiersUsed when two or more modifiers arenecessary to completely delineate aservice; the multiple modifiers usedmust be explained in the Remarks field(Box 80)/Additional Claim Informationfield (Box 19) of the claim.Do not bill 99 when billing split-billableclaims without a modifier (professionaland technical service component) orwith modifier 26 (professionalcomponent) and TC (technicalcomponent). The claim will be denied.Also used in special circumstances asspecified by the Department of HealthCare Services (DHCS). For anexample, refer to the Surgery BillingExamples:UB-04 or Surgery Billing Examples:CMS-1500 sections in the appropriatePart 2 manual.Part 2 – Modifiers: Approved List

modif app6Page updated: March 2021Table of Approved Modifiers (continued)ApprovedModifierNational Modifier DescriptionProgram-Specific Use of the Modifierand Special ConsiderationsAAAnesthesia performed by ananesthesiologistN/A‹‹AERegistered dieticianRegistered dietician››AGPrimary physicianSurgical: Used to denote a primarysurgeon. In the case of multiple primarysurgeons, two or more surgeons canuse modifier AG for the same patienton the same date of service if theprocedures are performedindependently and in different specialtyareas.This does not include surgical teams orsurgeons performing a singleprocedure requiring different skills. Anexplanation of the clinical situation andoperative reports by all surgeonsinvolved must be included with theclaim.‹‹Used by LEA to denote licensedphysicians.›› See Local EducationalAgency (LEA) in the appropriate Part 2manual for more information.AHClinical psychologist‹‹Used by LEA to denote licensedpsychologists, licensed educationalpsychologists, credentialed schoolpsychologists and clinicalpsychologists.›› See Local EducationalAgency (LEA) in the appropriate Part 2manual for more information.AIPrincipal physician of recordAllowable for all procedure codes.AJClinical social workerUsed by LEA to denote licensed clinicalsocial workers and credentialed schoolsocial workers. See Local EducationalAgency (LEA) in the appropriate Part 2manual for more information.Part 2 – Modifiers: Approved List

modif app7Page updated: March 2021Table of Approved Modifiers (continued)ApprovedModifierNational Modifier DescriptionProgram-Specific Use of the Modifierand Special ConsiderationsAPDetermination of refractive statewas not performed in the courseof diagnostic ophthalmologicalexaminationUse only for ophthalmology.ASPhysician assistant, nursepractitioner, or clinical nursespecialist services for assistant atsurgeryCertified nurse midwives (CNM) maybe reimbursed as an “assistant atsurgery” during cesarean sectiondeliveries performed by a licensedphysician and surgeon.AYItem or service furnished to anESRD patient that is not for thetreatment of ESRDN/AAZPhysician providing a service in adental health profession shortagearea for the purpose of anelectronic health record incentivepaymentN/A‹‹CO››‹‹Outpatient occupational therapyservices furnished in whole or inpart by an occupational therapyassistant››‹‹Used by LEA to denote licensedoccupational therapy assistant. SeeLocal Educational Agency (LEA) in theappropriate Part 2 manual for nt physical therapyservices furnished in whole or inpart by a physical therapistassistant)››‹‹Used by LEA to denote physicaltherapist assistant. See LocalEducational Agency (LEA) in theappropriate Part 2 manual for moreinformation.››CSCost-sharing for specifiedN/ACOVID-19 testing-related servicesthat result in an order for oradministration of a COVID-19 testPart 2 – Modifiers: Approved List

modif app8Page updated: March 2021Table of Approved Modifiers (continued)ApprovedModifierNational Modifier DescriptionProgram-Specific Use of the Modifierand Special ConsiderationsDAOral health assessment by alicensed health professional otherthan a dentistN/ADSAmbulance service origin code D(diagnostic or therapeutic siteother than P or H when these areused as origin codes) withambulance service destinationcode S (scene of accident oracute event)Medical transport dry run.E1NCCIassociatedUpper left, eyelidUse modifier SC with CPT code 68761(closure of lacrimal punctum; bythermocauterization, ligation, or lasersurgery; by plug, each) to indicate useof temporary collagen punctal plugs.Modifiers E1 thru E4 are used inconnection with permanent siliconepunctal plugs and procedures on theeyelids.E2NCCIassociatedLower left, eyelidUse modifier SC with CPT code 68761(closure of lacrimal punctum; bythermocauterization, ligation, or lasersurgery; by plug, each) to indicate useof temporary collagen punctal plugs.Modifiers E1 thru E4 are used inconnection with permanent siliconepunctal plugs and procedures on theeyelids.E3NCCIassociatedUpper right, eyelidUse modifier SC with CPT code 68761(closure of lacrimal punctum; bythermocauterization, ligation, or lasersurgery; by plug, each) to indicate useof temporary collagen punctal plugs.Modifiers E1 thru E4 are used inconnection with permanent siliconepunctal plugs and procedures on theeyelids.Part 2 – Modifiers: Approved ListWhen billed with modifier QN, modifierDS must be in the first modifierposition.