​Orthopedic surgeries are some of the most complex and delicate procedures in the field of medicine. In order to ensure that these procedures are carried out safely and efficiently, orthopedic surgeons require authorization from insurance companies. This process is known as prior authorization, and it can be time-consuming and cumbersome. That's why outsourcing prior authorization is becoming increasingly popular in the field of orthopedic surgery. In this article, we will discuss the importance of outsourcing orthopedic surgery prior authorization and how it can benefit both patients and healthcare providers.

​Prior authorization is a process used by insurance companies to determine whether they will cover the cost of a medical procedure or treatment. This process requires healthcare providers to submit detailed information about the procedure or treatment, including medical records, diagnosis codes, and treatment plans. Insurance companies review this information to determine whether the procedure or treatment is medically necessary and covered by the patient's insurance policy.

​Outsourcing prior authorization for orthopedic surgery can provide numerous benefits for healthcare providers and patients. By improving efficiency, reducing costs, and increasing accuracy, outsourcing can help healthcare providers provide high-quality care while ensuring that patients receive the necessary treatment in a timely and cost-effective manner. As the field of orthopedic surgery continues to evolve, outsourcing prior authorization will become an increasingly important tool for healthcare providers seeking to provide the best possible care for their patients.

​Guideline:
The same physician planned, at time of original surgery/procedure, a return trip to operating or procedure room within 10 or 90 day post op days



​

WHEN IT IS APPROPRIATE:

• Treatment of problem requiring a return to operating/procedure room
• More extensive than original procedure
• Unanticipated clinical condition
• Therapy following a diagnostic, surgical procedure                                
• Each case requires surgical documentation and evaluation

Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention

Physicians in same specialty, same group are to bill and are reimbursed as a single physician

Key to Remember!  Use modifier 78 (not 58!) for treatment problems unplanned requiring return trip to operating room

If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

It is NOT APPROPRIATE WHEN:

• Not appropriate for E/M - Evaluation and Management! or assistant surgery services

References:
CMS Medicare Website
Coding Books
​Payers Websites

Coding Billing for Medial and Lateral Nerve Blocks.

According to the AMA, the code series for medial branch blocks and the facet joint injections are the same (i.e., CPT series 64490-64495), with reporting based on the number of facet joints injected, not the number of nerves injected. 

For example: If three (3) medial branch nerves are injected only two (2) facet joint injection codes would be reported despite the fact that three nerves were injected, since each facet joint is connected to two medial nerves.

The lateral branch nerve is a peripheral nerve and would be reported with CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, when a lateral branch nerve block is performed.

Please note: CPT code 64450 should only be reported per nerve or branch and not per injection.

CPT code 76942, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation, would be additionally reported when utilizing ultrasound guidance for certain nerve block procedures when it is not inherent in the primary procedure code.

The Different kinds or types of NERVE BLOCKS and what are they targeting:
   
NERVE BLOCKS: Brachial plexus block, elbow block, wrist block BODY AREAS: Shoulder, arm, hand, elbow, wrist)
NERVE BLOCKS: Cervical epidural, thoracic epidural, lumbar epidural block BODY AREAS: Neck, back
NERVE BLOCKS: Cervical plexus block, cervical paravertebral block BODY AREAS: Shoulder, upper neck   
NERVE BLOCKS: Maxillary nerve block BODY AREAS: Upper jaw  
NERVE BLOCKS: Ophthalmic nerve block BODY AREAS: Eyelids, scalp   
NERVE BLOCKS: Sphenopalatine nerve block BODY AREAS: Nose, palate   
NERVE BLOCKS: Subarachnoid block, Celiac plexus block BODY AREAS: Abdomen, pelvis   
NERVE BLOCKS: Supraorbital nerve block BODY AREAS: Forehead   
NERVE BLOCKS: Trigeminal nerve block BODY AREAS: Face

CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA

CPT CODE 64490 PARAVERTEBRAL FACET JOINT BILLING AND CODING WITH IMAGING GUIDANCEInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64491 ----------- second level
64492 ----------- third and any additional level(s) level
CPT CODE 64493Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
64494 ----------- second level
64495 ----------- third and any additional level(s) level
​
FACET JOINT BILLING AND CODING WITH ULTRA-SOUND
0213T
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
....................................................................+ 0214T second level
....................................................................+ 0215T third and any additional level(s)
0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
..................................................................+ 0217T second level
..................................................................+ 0218T third and any additional level(s)
Billing and Coding for Radiofrequency Facet denervationCPT

CODE 64633
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint'

+64634 cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

CPT CODE 64635
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint;

+64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
​
Other Searched Keywords:
Billing and Coding for RFA of Facet Joint Nerves
Billing and Coding for Facet Joint AblationKey Points for CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA

These codes are unilateral

• Append Modifier 50 when its bilateral
• CPT 64490, 64493, 64495, 64633 are performed with Imaging Guidance; it's inappropriate to report these codes if its not with imaging guidance
• If its under ultra-sound, use the Category 3 Codes shown above
• You don't need Modifier 51 for the add-on codes +64491, +64496, +64634, +64636
• Place of Service applicable to POS 11, 24, 22

Let's look at these questions and answers:
#1 Question
"What are the appropriate code assignments when a patient receives 3 separate nerve blocks into the same lateral branch nerve? Would it be appropriate to report 3 units of this service?"
The right CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, would be appropriately reported only once in this case since all 3 nerve blocks were administered to the same nerve or branch.

#2 Question
"We are getting conflicting information regarding coding medial and lateral branch blocks S1, S2, and S3, Medial 64493, 64494, Lateral 64493, and 64494. Our Pain Center wants to use facet injection for the medial branch block and other peripheral nerve for the lateral branch block. Are we correct in reporting lateral branch nerve block(s) to the peripheral nerve CPT code?" Yes, you are correct. The lateral branches of the dorsal sacral nerve plexus are considered peripheral nerves. Therefore, for the four lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch. Report multiple units of the injection for the four lateral branch block injections performed, modifier 59 would not be appended in this case.

# 3 Question
"A patient was seen at our facility and underwent a left-sided L5 and S1, S2, S3, and S4 lateral branch nerve block for diagnostic purpose with C-arm fluoroscopy. What are the correct codes for a lateral nerve block?"

So OK, ... based on the operative report a medial branch nerve block was performed at the L5 and a lateral branch nerve block was performed at the S1, S2, S3 and S4

Therefore, it would be appropriate to report CPT code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapohphyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level, for the L5 medial branch block.

For the 4 lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch.

References:
2017 / 2018 Coding Books (CPT is a Trademark and Owned by the American Medical Association)
AMA's CPT Assistant Archives
CMS Medicare Website (LMN, NCD/LCD, Manuals)
Commercial Payers Guidelines

Definition: Bilateral Procedure; procedures/services that occur on identical, opposing structures (such as for example - "LEFT" and "RIGHT" Side)
Many Billers are still really confused on how Modifier 50 really works. 

APPROPRIATE:

• When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule BILAT SURG indicator is 1: 
• Report codes with a BILAT SURG indicator of 1 on one line, appending modifier 50 and submit one unit of service. 

For example: 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 

Billed as 64490 -50  1 unit

• When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule (MPFS) BILAT SURG indicator is 3: 
• Submit codes with a BILAT SURG 3 on one line appending either modifier 50 using one unit of service (UOS); or 
• Submit codes on one line with two UOS (the use of the RT/LT modifiers would be optional); or 
• Submit on two lines of service using RT on one line and LT on the other with one UOS each.

INAPPROPRIATE:

• Reporting this modifier when performing the service on different areas of the same side of the body. 
• The BILAT SURG indicator is 0, 2, or 9. 
• When removing a lesion on the right arm and one on the left arm - use the RT and LT modifiers. 
• Do not use modifier 50 for multiple procedures on one organ, such as the skin. 
• On a procedure code that is described as bilateral or unilateral or bilateral in its CPT description. 
• Do not report a bilateral procedure on two lines of service appending modifier 50 to the second line of service.

Coding Tip:
Generally speaking, the above information applies when two of the same procedure codes are performed on the same day for the same patient by the same provider. However, there could be instances where two separate procedure codes are used. If so, Medicare's payment or denial would depend on any other type of rules or regulations concerning the individual services in question. This could include the National Correct Coding Initiative (NCCI) that could necessitate additional modifiers, duplicate edits, and global surgery edits.

Remember, the Modifier 50 is used as a payment, rather than informational, modifier. The addition of this modifier could affect payment depending on the procedure code and the BILAT SURG indicator. The BILAT SURG indicator for each procedure code can be found on the Medicare Physician Fee Schedule Relative Value File. Following are the indicators and their descriptions.

BILAT SURG indicator "0" =150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides and (b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

BILAT SURG Indicator "1" =150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

Reference Manual:
The CMS Internet-Only Manual, Publication 100-04, Chapter 12 , Section 40.7.B, indicates "If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physician must report the procedure with modifier "-50". They report such procedure as a single line item."

BILAT SURG Indicator "2" =150% payment adjustment does not apply. Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure.

BILAT SURG Indicator "3" = the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any multiple procedure rules. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries.

BILAT SURG Indicator "9" = The bilateral payment adjustment concept does not apply.

Ambulatory Surgical Centers (ASCs) and Modifier 50

Bilateral surgical procedures furnished by certified ASCs may be covered under Part B. While use of the 50 modifier is not prohibited according to Medicare billing instructions, the modifier is not recognized for payment purposes and if used, may result in incorrect payment to ASCs.

Bilateral procedures should be reported as a single unit on two separate lines or a single unit with "2" in the unit field on one line, in order for both procedures to be paid correctly. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting.

Read more examples for appropriate billing procedures in the MLN Matters article,

"Revised Payment System for Ambulatory Surgical Centers (ASC) in Calendar Year (CY) 2008"  (Revised SE 0742).

References:
CMS: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Noridian: https://med.noridianmedicare.com/web/jeb/specialties/surgery/bilateral-surgery
American Medical Association Coding Guidelines

​Definition: Unrelated evaluation and management (E/M) service by the same physician* during a postoperative period 

APPROPRIATE:

• Append modifier 24 to the E/M procedure code (Not Procedure Codes!)
• Use on an unrelated E/M service beginning the day after a procedure, when the E/M is performed by the same physician* during the 10 or 90 day post-operative period. 
• Use modifier 24 on the E/M if documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care. 
• Use modifier 24 on the E/M code when the same physician* is managing immunosuppressant therapy during the post-operative period of a transplant. 
• Use modifier 24 on the E/M code when the same physician* is managing chemotherapy during the post-operative period of a procedure. 
• When the same physician* provides unrelated critical care during the post-operative period. 

INAPPROPRIATE:

• Do not use when the E/M is for a surgical complication or infection. This treatment is part of the surgery package. 
• Do not use when the service is removal of sutures or other wound treatment. This treatment is part of the surgery package. 
• Do not use when the surgeon admits a patient to a skilled nursing facility for a condition related to the surgery. 
• Do not use unless the medical record documentation clearly indicates the E/M was unrelated to the surgery. 
• Do not use outside of the post-op period of a procedure. 
• Do not use on the same day as a procedure. 

*Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."

Reporting Multiple Surgery Modifiers on the Same Claim Line
The following is an example of appropriate reporting of both modifiers 24 (Unrelated E/M by the same physician during a postoperative period), and 25 (Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service), on the same E/M code.

Many are still confused on this. But here... 
"A physician performs a major surgery and within the global period sees the patient for an unrelated E/M visit. During this unrelated E/M visit, the physician determines the necessity of a minor surgery or other procedure. This minor surgery/other procedure is significant and separately identifiable from the E/M and unrelated to the original major surgery. Both the 24 and 25 modifiers are appropriate to add to the E/M code. The 24 modifier is appropriate because the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is necessary to identify that the minor surgery/procedure performed on the same day is separately identifiable from the E/M service. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery."

Definition: Increased Procedural Service requiring work substantially greater than typically required.

The RIGHT WAY:

• Surgeries where services performed are significantly greater than usual. 
• Anatomical variants could be an appropriate use of the modifier. 
• Assistant at surgery claims where a procedure is significantly greater than usual. 
• Procedures having a global surgery indicator of 000, 010, or 090 on the Medicare Physician Fee Schedule Database (MPFSDB). 
• Procedures having a global period but not surgical services (i.e. 77761, 77777, 77782).

Inappropriate:

• Additional time alone does not justify the use of this modifier (very important to KNOW!)
• Do not use when there is an existing code to describe the service. 
• We may deny the claim when the documentation supports another existing code. 
• Do not use to indicate a specialist performed the service. 
• Not appropriate for an Evaluation and Management (E/M) service.
• Documentation

Indicate "additional information available upon request" in field 19 of the 1500 Claim Form.

When the modifier 22 is used, two separate documents will be required to support the claim: 

• An operative report; and 
• A separate statement indicating how the service differs from the usual

Important Information for Billing and Documentation

Based on Medicare's Guideline of which most payers does follow Medicare's Guideline. So pay attention on this:

If you append a 22 modifier to a procedure you will receive an Additional Documentation Request (ADR) letter requesting medical records to support the use of the 22 Modifier. It is important that both the operative report and a separate concise statement on why it was beyond the normal difficulty be returned with a copy of the ADR letter. Failure to submit the statement and documentation in a timely fashion will result in processing of the claim with the fee schedule rate for the same surgery submitted without the 22 modifier.

Documentation Tips:
When developing a separate statement avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specific details which identify why the procedure was beyond the normal difficulties that could be encountered with the procedure. Further, it is important that your operative note supports the statement on why the surgical procedure was beyond the ordinary range of difficulty.

Unassigned Claim
For unassigned claims, an increase in the limiting charge is allowed only when a charge above the fee schedule amount is justified.

Reference CMS Manual Instruction:
The CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12 , Section 20.4.6 shows the requirements for using this modifier.

How to use MODIFIERS for MEDICAL AND GLOBAL SURGERY Encounters - GoHealthcare is a Leader in Revenue Cycle Management.

I have shared a lot of guidelines on each of this modifier. But today, this blog post will cover from Modifier 22 to Modifier 99. So are you ready? Make sure to click on "DIG DEEPER" for learn more and read more on clinical scenario samples.

All of these guidelines are based on Medicare's Guidelines. References are attached on each guideline. I strongly believe 98% of all the commercial payers does follow Medicare's Guidelines. Period.

​Modifier 22
Increased Procedural Services (Dig Deeper to learn more ... CLICK HERE)

Modifier 23
Unusual Anesthesia

Modifier 24
Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period (Dig Deeper to learn more ... CLICK HERE)

Modifier 25
Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

Modifier 26
Professional Component

Modifier 27
Multiple Outpatient Hospital E/M Encounters on the Same Date

Modifier 32
Mandated Services

Modifier 33
Preventive Services

Modifier 47
Anesthesia by Surgeon

Modifier 50
Bilateral Procedure (Dig Deeper to learn more ... CLICK HERE)

Modifier 51
Multiple Procedures

Modifier 52
Reduced Services

Modifier 53
Discontinued Procedure

Modifier 54
Surgical Care Only

Modifier 55
Postoperative Management Only

Modifier 56
Preoperative Management Only

Modifier 57
Decision for Surgery (Dig Deeper to learn more ... CLICK HERE)

Modifier 58 
Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period (Dig Deeper to learn more ... CLICK HERE)

Modifier 59
Distinct Procedural Service (Dig Deeper to learn more ... CLICK HERE)

Modifier 62
Two Surgeons

Modifier 63
Procedure Performed on Infants less than 4 kg
 
Modifier 66
Surgical Team
 
Modifier 73
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia
 
Modifier 74
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia
 
Modifier 76
Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
 
Modifier 77
Repeat Procedure by Another Physician or Other Qualified Health Care Professional
 
Modifier 78
Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
 
Modifier 79
Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period (Dig Deeper to learn more ... CLICK HERE)
 
Modifier 80
Assistant Surgeon
 
Modifier 81
Minimum Assistant Surgeon

Modifier 82
Assistant Surgeon (when qualified resident surgeon not available)
 
Modifier 90
Reference (Outside) Laboratory
 
Modifier 91
Repeat Clinical Diagnostic Laboratory Test
 
Modifier 92
Alternative Laboratory Platform Testing
 
Modifier 95
Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System
 
Modifier 96
Habilitative Services
 
Modifier 97
Rehabilitative Services
 
Modifier 99
Multiple Modifiers

Techniques:

• Posterior Lumbar Interbody Fusion (PLIF) * Incision is performed through a midline incision in the back

Image Source: https://www.slideshare.net/drpraveenktripathi/lumbar-interbody-fusion-indications-techniques-and-complications

• Transforaminal Lumbar Interbody Fusion (TLIF) * Incision is also performed through a midline incision in the back, only on the side of the spine, to access the vertebral body at an angle

​​Both Procedures (PLIF and TLIF) allows for an Anterior Interbody Fusion through a Posterior Approach. The Interbody space is part of the anterior column of the spine.

22630
Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
+22632
Each Additional interspace (list separately in addition to code for primary procedure code)
​
Here's what occurs when 22630 is performed:
The provider performs an arthrodesis, also known as spinal fusion, in the lumbar spine, or lower back, to permanently join two vertebrae, the interlocking bones of the spine. He excises the lamina and disk material and applies bone graft between the disks to fuse them. The procedure helps to alleviate persistent pain caused by various spinal conditions, including herniated intervertebral disks, stenosis, or spinal injuries.

Then, in 2012 
Code  22633 was introduced to to represent the combination of 22630 and 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) at the same level.

22558
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 
Remember: (For arthrodesis using pre-sacral interbody technique, see 22586, 0195T)
+22585
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) 
Remember: (Use 22585 in conjunction with 22554, 22556, 22558) 
(Do not report 22585 in conjunction with 63075, even if performed by a separate individual. To report anterior cervical discectomy and interbody fusion at the same level during the same session, use 22552)

Here's what occurs when 22558 is being performed:
The provider performs arthrodesis, also known as spinal fusion, in the lower back, to permanently join two vertebrae, the interlocking bones of the spine, to alleviate persistent pain caused by a herniated, or bulging, disk, or other spinal condition. He makes an incision in the abdomen to access the spine and remove disk material.

POSTERIOR INSTRUMENTATION:

Add-Code +22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
(Use 22840 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307)

Add-On Code +22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)

Add-On Code +22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
Use 22842 in conjunction with 22100- 22102, 22110- 22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)Text has been updated

Add-On Code +22843 7 to 12 vertebral segments (List separately in addition to code for primary procedure)
(Use 22843 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081,63085, 63087, 63090, 63101, 63102, 63170-63290,63300- 63307)Text has been updated

Add-On Code +22844 13 or more vertebral segments (List separately in addition to code for primary procedure)
(Use 22844 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)

ANTERIOR INSTRUMENTATION
Add-On Code +22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
(Use 22845 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081,63085, 63087, 63090, 63101, 63102, 63170-63290,63300- 63307)Text has been updated

Add-On Code +22846 4 to 7 vertebral segments (List separately in addition to code for primary procedure)
Use 22846 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)Text has been updated

Add-On Code +22847 8 or more vertebral segments (List separately in addition to code for primary procedure)
(Use 22847 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040- 63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290,63300-63307)Text has been updated

Add-On Code +22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)
(Use 22848 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)​

22853
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) 
Notes:
(Use 22853 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307) 
(Report 22853 for each treated intervertebral disc space)

Code +22853 is one of several new codes within the spine section for the insertion of biomechanical devices that replace deleted code +22851 (Application of intervertebral biomechanical device[s] ...). The new add-on codes are more specific regarding the type and location of the biomechanical devices.

CPT® guidelines direct you to report +22853 for each treated intervertebral disc space.
Report +22853 in addition to the definitive procedure(s) since it is an add-on code.

Do not append modifier 62 (Two surgeons) to 22853.

The provider inserts a metallic cage or mesh device between two vertebrae and may use screws or flanges to attach it to the front part of the vertebrae; the device maintains the disc space, provides spinal stability, and yet preserves some range of motion, which helps relieve persistent pain caused by a herniated, or bulging, disk or other spinal condition. The provider performs this procedure during a spinal interbody arthrodesis procedure, which is fusion, or permanent joining, of vertebrae over the joint space.

Remember!
Code +22853 is an add–on code and must be reported with an appropriate primary procedure, such as 22548–22586 (Anterior or anterolateral approach technique arthrodesis procedures on the spine [vertebral column]), but there are many other codes that can be reported as a primary code.

Report one unit of this code for each interspace treated, not for the number of devices inserted. For example, if the provider inserts two cages into a single interspace, you report this code only once. If the provider inserts a device at two separate interspaces, e.g., between C3–4 and C5–6, then you would report this code twice.

This code is for the application of a device to expand or maintain an intervertebral disc space.

For a similar procedure to cover a defect created by removal of a vertebral body,
report 22854 (Insertion of intervertebral biomechanical device(s) [e.g., synthetic cage, mesh] with integral anterior instrumentation for device anchoring [e.g., screws, flanges], when performed, to vertebral corpectomy[ies] [vertebral body resection, partial or complete] defect, in conjunction with interbody arthrodesis, each contiguous defect [List separately in addition to code for primary procedure]).

For insertion of a similar device to treat an intervertebral disc space or vertebral body removal defect but without interbody fusion (arthrodesis), report 22859 (Insertion of intervertebral biomechanical device[s] [e.g., synthetic cage, mesh, methylmethacrylate] to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect [List separately in addition to code for primary procedure]).

20930
Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) 
Notes:
(Use 20930 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)

Here's what occurs when 20930 is being performed;
The provider applies small pieces of donor or synthetic bone graft material during a spinal surgery to encourage bone growth during the healing period. 

Coding Tip!
Code 20930 is an add on code and used for specified spinal procedures only.

Check with your payer to determine if 20930 can be billed separately or if the application of the bone graft material is included in the code for the primary surgical procedure. 

Do not append modifier 62 to bone graft codes 20900-20938. 

(For spinal surgery bone graft[s] see codes 20930-20938)

Check with your payer if you can separately report this code;

+20931
Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) 
Notes:
(Use 20931 in conjunction with 22319, 22532-22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)
A provider uses a structural allograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure.

Coding Tips:
Code 20931 is an add on code describing application of structural allograft to spinal defects and must be reported with an allowable primary spinal procedure code.

Report 20930, Allograft, morselized, or placement of osteopromotive material, for spine surgery only, together with 20931 only in the case of a human donor who is a different person from the recipient.

You should never append modifier 50, Bilateral procedure, to 20931. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply.

+20936
Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) 
Notes:
(Use 20936 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)

A provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient’s own bone, taken from the same surgical incision.

Coding Tips:
Code 20936 is an add on code describing grafting from a donor area using the same incision during a major operative procedure and must be reported with an allowable primary spinal procedure code.

You should never append modifier 50, Bilateral procedure, to 20936. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply.

+20937
Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) 
Notes:
(Use 20937 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)

The provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient’s own body during the surgical procedure, through a separate incision.

Coding Tips:
Code 20937 is an add on code describing preparation and application of a morselized autograft through a separate skin incision and must be reported with an allowable primary spinal procedure code.


*** A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies which contains the intervertebral disc, and includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates. 

Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) 
Notes:
(Use 20938 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812) 

(For aspiration of bone marrow for bone grafting, spine surgery only, use 20939)

The provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient's own body during the surgical procedure, through a separate incision.

Source: CPT®  Assistant July 1996 page 7
Coding Tip
Reporting Cosurgeries
"We receive many questions concerning how to report surgeries performed by more than one physician. To help you understand the proper coding we present the following information."
The General Question
"I am a general surgeon who sometimes performs surgeries with other surgeons (cosurgeries), such as orthopedic or neurosurgeons. I open the surgical site, the other surgeon does the definitive portion of the procedure, and then I close. What CPT codes should I report for my services? I have heard from some sources that I should bill for a thoracotomy and wound repair. But other sources have told me to report the same CPT codes as the other surgeon. Which is correct?

CPT® ​ASSISTANT'S REPLY:
Here's How to Code:
"For situations in which one surgeon performs the opening and closing of a surgery and another physician performs the definitive portion of the procedure, both physicians should report the same CPT codes, and appropriately append either modifier -62 or modifier -66."

Illustration
A patient's surgery includes arthrodesis of two interspaces of the thoracic spine by anterior interbody technique, with anterior instrumentation of three vertebral segments. Physician "A" performs a thoracotomy at the start of the surgical session, and Physician "B" performs the arthrodesis and spinal instrumentation. Upon completion of the arthrodesis and spinal instrumentation, Physician A closes the operative site. 
Coding the Illustration
(The physicians in the illustration would report the codes indicated below.)
Physician A       22556-62
Physician B       22556-62
22558-62
22558-62

22845-62
22845-62
When performing these cosurgeries, it is important to communicate with the other surgeon's office to be certain that you submit the claims properly

CPT®  Guideline September 1997 page 8
Coding Communication
How to Code Prosthetic Devices
It is not often that we devote an entire article to a single code, but sometimes this is the only way to fully explain the use of certain codes-22851, application of prosthetic device (eg, metal cages, methylmethacrylate) to vertebral defect or interspace, is such a code. But before we review how to report this code, it is probably a good idea to first do a brief anatomical review of the vertebral column.

The vertebral column (spine) consists of a series of bones known as vertebrae.


An adult human possesses 33 vertebrae divided into the following five types:

    7 cervical vertebrae;

    12 thoracic vertebrae;

    5 lumbar vertebrae;

    5 sacral vertebrae; and

    4 coccygeal vertebrae. 

The sacral vertebrae are typically fused into a single bone known as the sacrum. The coccygeal vertebrae are sometimes fused into a single bone known as the coccyx.

Therefore, the actual number of bones in the vertebral column may be 26-29, depending on if the coccygeal vertebrae are fused. Vertebrae are commonly named by a letter that corresponds to the region of the vertebral column to which the vertebrae belongs, followed by a number that indicates where in the region the vertebrae is located. For example, the most superior cervical vertebra is called C1, with the next cervical vertebrae down designated C2. The most superior thoracic vertebrae is T1, with the next one down designated T2.

Fig. 1 - Spinal Prosthetic Devices
Between each pair of vertebrae is a disc that cushions the spinal column. If one of the discs degenerates or if one of the 26-29 vertebrae are injured (as in the case of a fracture, degenerative disease, or secondary to tumor destruction) the physician may need to place a prosthetic device (eg, metal cages or methyl-methacrylate) in the vertebral defect or interspace. (Fig. 1) In these instances, a segment of vertebral level may be drilled and metal cages packed with porous implants of bone graft may be inserted or methylmethacrylate may be placed between the affected vertebrae.

Proper Reporting of code 22851
It is important to note that CPT®  code 22851 is not intended to be reported per cage.

CPT®  code 22851 should only be reported one time, regardless if one or more metal cages are placed in the intervertebral space at the same level. However, if metal cages are placed at two different levels, (eg, metal cage placed at L3-4 interspace and L5-S1 interspace), then 22851 may be reported more than once to indicate that one or more cages were placed at two or more different levels. It is important to note that a single cage or methylmethacrylate can cover a defect of several vertebral segments (eg, a single cage may replace three entire vertebrae), wherein code 22851 would still only be reported one time.

Within the spine section, instrumentation procedure codes (22840-22855) are reported in addition to the definitive procedure(s) without appending the modifier -51. Therefore, if arthrodesis is performed in addition to the placement of the metal cages, then it would be appropriate to report code 22851 in addition to the appropriate arthrodesis code, 22548-22632. In this instance, the modifier -51 would not be appended to code 22851. 

If metal cages are placed through an anterior approach and pedicle screws are placed through a posterior approach, it would be appropriate to report both code 22851 and one of the codes from the posterior instrumentation series, 22840, 22842-22844. However, if different instrumentation is used in addition to the metal cages or methylmethacrylate through the same approach (eg, an anterior plating system) or pedicle screws and posterior lumbar interbody fusion utilizing cages), then the appropriate instrumentation code would be reported in addition to code 22851. However, 22851 and 22845 should not both be reported if only the metal cage is inserted.
If fracture treatment, dislocation, or arthrodesis is performed in addition to spinal instrumentation, then the appropriate fracture treatment, dislocation or arthrodesis code (22325, 22326, 22327, 22548-22812) would be reported separately in addition to code 22851. In this instance, CPT®  code 22851 would be reported in addition to the definitive procedure(s) without the modifier -51 appended.
If bone grafting is performed in addition to code 22851, then the appropriate bone grafting code, 20930-20938, would be reported additionally.
Clinical Sample:
CPT® Code 22851
A 50-year-old man undergoes an anterior fusion of L5-S1 for degenerative disease. A retroperitoneal incision is made and an arthrodesis performed using a BAK cage. A distracter is placed in the interspace, a hole is drilled in the interspace, and the BAK cage is placed in the hole. The spacer is removed and replaced with another BAK cage. Both cages are filled with bone graft. (Report arthrodesis and/or bone grafting separately using the appropriate CPT code[s]).

The exposed disk space and adjacent vertebrae are prepared with bone-cutting instruments for acceptance of the prosthetic device. Preparation of the recipient site is made according to the protocol of the particular device. If methylmethacrylate is to be used, a screw or pin may be inserted into the adjacent vertebral surfaces to anchor the methylmethacrylate. Provision is made for cooling of adjacent tissues and protection of heat sensitive tissue from the exothermic reaction of the curing of the methylmethacrylate. For cages, the recipient site is prepared by bone dissection, a trial fit with the device or a spacer or template as indicated by the protocol is inserted and removed for any final modifications of the recipient site. The prosthetic device is then screwed, impacted, or injected into place according to protocol for this particular device. (Additional fixation, other provision for arthrodesis, or bone grafting are coordinated with the placement of the prosthetic device and are coded separately.) For devices that incorporate graft material, that material is appropriately placed into the device prior to its final insertion.

CPT®  ASSISTANT September 2000 page 10
Coding Consultation
Musculoskeletal System, Surgery, 22548-22585, 22899 (Q&A)

Question
"Should I use the anterior or anterolateral approach technique arthrodesis series of codes (22548-22585) to report intra-abdominal laparoscopic, video assisted anterior interbody fusion?"

AMA CPT®  Comment
"The anterior or anterolateral approach technique arthrodesis series of codes (22548-22585) are intended to describe arthrodesis performed via an open surgical approach. There is not a specific CPT code that accurately describes laparoscopic anterior interbody fusion. Therefore, code 22899, Unlisted procedure, spine should be reported. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time limit, effort, and equipment necessary to provide the service."

CPT®  ASSISTANT March 2015 page 9
Frequently Asked Questions:Surgery: Musculoskeletal System

Question: "Are CPT codes 22851 and 22845 appropriate to report when modular implants, such as the RSB (RSB LLC; Cleveland, OH) InterPlate® (a modular interbody platform technology), are implanted for spinal fusion procedures?"

Answer:
"No. The RSB InterPlate® describes a stand-alone interbody fusion device that consists of an interbody spacer with screw fixation or other mechanisms, which engage adjacent vertebrae. Such devices should be reported with code 22558, Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar, and 22851, Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure). An additional anterior instrumentation code (22845) is not applicable because there is no separate construct placed across the vertebral segment."

Question: "Would it be appropriate to separately report any of the following with the hammertoe correction code 28285 (2nd digit), if adequately documented? (1) Resection of hypertrophied base of proximal phalanx (28126), if performed through a separate incision at the metatarsophalangeal (MTP joint); (2) flexor tenotomy (28232) performed through a separate incision at the distal interphalangeal (DIP) joint; (3) an additional unit of 28285 if K-wire is inserted through the DIP, MTP, or proximal interphalangeal (PIP) joint."

Answer:
"No. Code 28126, Resection, partial or complete, phalangeal base, each toe; code 28232, Tenotomy, open, tendon flexor; toe, single tendon (separate procedure); and the insertion of K-wire through DIP, PIP, and MTP joints are all inclusive components of the procedure described by code 28285, Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy), and should not be reported separately."

References:
2020 AMA's CPT®  Guidelines
2019 AMA's CPT®  Guidelines
2018 AMA's CPT®  Guidelines
2017 AMA's CPT®  Guidelines
CPT® Assistant Archives

​Websites:
NASS
​Spine-Health
Medtronic
Ahima
AAPC
CMS
​All other commercial payers clinical guidelines from the public domains on the internet
​

​Keypoints:

• Make sure you have identified medical necessity for a DME Durable Equipment Item
• Make sure you have documented the necessity
• Make sure you have a delivery receipt that the patient had received the DME Item
• Make sure you are reporting the right DME Item
• Make sure you are reporting the right place of service
• Make sure you have checked with your payer how they want you to report the DME Item on your Claims

RR — RENTAL. (USE THIS 'R' MODIFIER WHEN DME IS TO BE RENTED)
This modifier is used for DME items that are rented, and will be used for equipment in the following categories:

• Inexpensive or other Routinely purchased DME (IRP)
• Frequent or Substantial Servicing (FS)
• Certain customized items:
  • Other Prosthetic and Orthotic Devices (P & O)
  • Capped Rental Items (CR)
  • Oxygen and Oxygen Equipment

KH — DMEPOS ITEM, INITIAL CLAIM, PURCHASE OR FIRST MONTH RENTAL
This modifier is used for a capped rental DME item. When using the KH modifier, you are indicating you are billing for the first month of the capped rental period.
KJ — DMEPOS ITEM, PARENTERAL ENTERAL NUTRITION (PEN) PUMP OR CAPPED RENTAL, Month four to fifteen. This modifier is used for capped rental DME items. When using the KJ modifier, you are indicating you are billing for months four through thirteen/fifteen of the capped rental period.
KI — DMEPOS ITEM, SECOND OR THIRD MONTH RENTAL
This modifier is used for capped rental DME items. When using the KI modifier, you are indicating you are billing for the second and/or third month of the capped rental period
A8 — DRESSING FOR EIGHT WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A5 — DRESSING FOR FIVE WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A4 — DRESSING FOR FOUR WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A9 — DRESSING FOR NINE OR MORE WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A1 — DRESSING FOR ONE WOUND. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A7 — DRESSING FOR SEVEN WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A6 — DRESSING FOR SIX WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A3 — DRESSING FOR THREE WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A2 — DRESSING FOR TWO WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
KA — ADD ON OPTION/ACCESSORY FOR WHEELCHAIR (EFFECTIVE DATE 01/01/1994)
JA — ADMINISTERED INTRAVENOUSLY (EFFECTIVE DATE 01/01/2007)
N/A
JB — ADMINISTERED SUBCUTANEOUSLY (EFFECTIVE DATE 01/01/2007)
For all immune globulin (J1559, J1561, J1562, J1569) and associated infusion pump (E0779) claims where the route of administration is subcutaneous, a JB modifier must be added to each HCPCS code.
VP — APHAKIC PATIENT (EFFECTIVE DATE 01/01/1984)
N/A
TW — BACK-UP EQUIPMENT (EFFECTIVE DATE 01/01/2003)
N/A
KB — BENEFICIARY REQUESTED UPGRADE FOR ABN, MORE THAN 4 MODIFIERS IDENTIFIED ON CLAIM. (EFFECTIVE DATE 1/1/2003)
N/A
KT — BENEFICIARY RESIDES IN A COMPETITIVE BIDDING AREA AND TRAVELS OUTSIDE THAT COMPETITIVE BIDDING AREA AND RECEIVES A COMPETITIVE BID ITEM (UPDATED DATE 04/01/2008
N/A
KE — BID UNDER ROUND ONE OF THE DMEPOS COMPETITIVE BIDDING PROGRAM FOR USE WITH NON-COMPETITIVE BID BASE EQUIPMENT (EFFECTIVE 01/01/2009)
This is a pricing modifier and it used with certain items that may be used with competitive or non-competitive bid items. Use of the KE indicates the 9.5% reduction should not affect your reimbursement.
CR — CATASTROPHE/DISASTER RELATED
For use by providers that have been granted a formal waiver under §1135 of the Social Security Act and then only for services affected by the emergency and while the waiver remains in effect.
QQ — CLAIM SUBMITTED WITH A WRITTEN STATEMENT OF INTENT
CT — COMPUTED TOMOGRAPHY SERVICES FURNISHED USING EQUIPMENT THAT DOES NOT MEET EACH OF THE ATTRIBUTES OF THE NATIONAL ELECTRICAL MANUFACTURERS ASSOCIATIONS (NEMA) XR-29-2013 STANDARD
N/A
PD — DIAGNOSTIC OR RELATED NON DIAGNOSTIC ITEM OR SERVICE PROVIDED IN A WHOLLY OWNED OR OPERATED ENITY TO A PATIENT WHO IS ADMITTED AS AN INPATIENT WITHIN 3 DAYS (EFFECTIVE DATE 01/01/2012)
KL — DMEPOS ITEM DELIVERED VIA MAIL (EFFECTIVE DATE 07/01/2007)
When using this modifier, you are indicating you have delivered your supplies via mail. This modifier must only be used with diabetic supplies.
KG — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 1 (EFFECTIVE DATE 07/01/2007)
KK — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 2 (EFFECTIVE DATE 07/01/2007)
KU — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 3 (EFFECTIVE DATE 07/01/2007)
N/A
KW — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 4 (EFFECTIVE DATE 1/1/2008)
N/A
KY — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 5 (EFFECTIVE DATE 1/1/2008)
N/A
KV — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED AS PART OF A PROFESSIONAL SERVICE (EFFECTIVE DATE 1/1/2008)
N/A
J4 — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED BY A HOSPITAL UPON DISCHARGE (EFFECTIVE 01/01/2010)


JW — DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT (EFFECTIVE 01/01/2003)
For CGS DMEMAC claims, the JW modifier is not required for discarded drugs and biologicals.
KD — DRUG OR BIOLOGICAL INFUSED THOUGH DME. (EFFECTIVE DATE 01/01/04)
RD — DRUG PROVIDED TO BENEFICIARY, BUT NOT ADMINISTERED 
EM — EMERGENCY RESERVE SUPPLY (FOR ESRD BENEFIT ONLY).
ET — EMERGENCY SERVICES
EA — ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO ANTI-CANCER CHEMOTHERAPY (EFFECTIVE DATE 1/1/2008)
EB — ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO ANTI-CANCER RADIOTHERAPY (EFFECTIVE DATE 1/1/2008)
EC — ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA NOT DUE TO ANTI-CANCER RADIOTHERAPY OR ANTI-CANCER CHEMOTHERAPY (EFFECTIVE DATE 1/1/2008)
EX — EXPATRIATE BENEFICIARY
Effective July 1, 2016, use this modifier to bill Medicare for purchased only DMEPOS items that are furnished to expatriate beneficiaries. By attaching the EX modifier, the supplier is attesting that the benefidicary is an expatriate beneficiary, and that the item was delivered/furnished while the beneficiary is present in the U.S., and all other billing criteria has been met.
QA — FDA INVESTIGATIONAL DEVICE EXEMPTION (ENDS 12/31/2007)
KP — FIRST DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION
When there is a single drug in a unit dose container, the KO modifier is added to the unit dose form code. (Exception: The KO modifier is not used with code J2545 or Q4080.) Except for code J7620, when two or more drugs are combined and dispensed to the patient in the same unit dose container, each of the drugs is billed using its unit dose form code. The KP modifier is added to only one of the unit dose form codes and the KQ modifier is added to the other unit dose code(s). Whenever a unit dose form code is billed, it must have a KO, KP or KQ modifier. (Exception: The KO, KP and KQ modifiers should not be used with code J7620.) If a unit dose code does not have one of these modifiers, it will be denied as an invalid code. The KO, KP, and KQ modifiers are not used with the concentrated form codes. The only FDA-approved unit dose preparation containing more than one drug is J7620, the combination of albuterol and ipratropium. Therefore, if the following FDA-approved unit dose codes are billed with a KP or KQ modifier, they will be rejected as invalid for claim submission: J2545, J7608, J7613, J7614, J7626, J7631, J7639, J7644, J7649, J7659, J7669, J7682, Q4080, and Q4080.
RE — FURNISHED IN FULL COMPLIANCE WITH FDA-MANDATED RISK EVALUATION AND MITIGATION STRATEGY (REMS) (EFFECTIVE 01/01/2009)
KS — GLUCOSE MONITOR SUPPLY FOR DIABETIC BENEFICIARY NOT TREATED WITH INSULIN
If the patient is not being treated with insulin injections, the KS modifier must be added to the code for the monitor and each related supply on every claim submitted.
ED — HEMATOCRIT LEVEL HAS EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS EXCEEDED 13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO AND INCLUDING THE CURRENT CYCLE (EFFECTIVE DATE 1/1/2008)
EE — HEMATOCRIT LEVEL HAS NOT EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS NOT EXCEEDED 13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO AND INCLUDING THE CURRENT CYCLE (EFFECTIVE DATE 1/1/2008)
Q0 — INVESTIGATIONAL CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN APPROVED CLINICAL RESEARCH STUDY (EFFECTIVE DATE 1/1/2008)
KF — ITEM DESIGNATED BY FDA AS CLASS III DEVICES. (EFFECTIVE DATE 04/01/04)
AV — ITEM FURNISHED IN CONJUNCTION WITH A PROSTHETIC DEVICE, PROSTHETIC OR ORTHOTIC. (EFFECTIVE DATE 1/1/2003)
AW — ITEM FURNISHED IN CONJUNCTION WITH A SURGICAL DRESSING. (EFFECTIVE DATE 1/1/2003)
AU — ITEM FURNISHED IN CONJUNCTION WITH A UROLOGICAL, OSTOMY, OR TRACHEOSTOMY SUPPLY. (EFFECTIVE DATE 1/1/2003)
This modifier is used specifically with codes A4450, A4452, and A5120.
AX — ITEM FURNISHED IN CONJUNCTION WITH DIALYSIS SERVICES. (EFFECTIVE DATE 1/1/2003)
BA — ITEM FURNISHED IN CONJUNCTION WITH PARENTERAL ENTERAL NUTRITION (PEN) SERVICES. (EFFECTIVE DATE 1/1/2003)
When an IV pole (E0776) is used in conjunction with parenteral nutrition, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.
GZ — ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE OR NECESSARY. (EFFECTIVE 1/1/2002)
AY — ITEM OR SERVICE FURNISHED TO AN ESRD PATIENT THAT IS NOT FOR THE TREATMENT OF ESRD (EFFECTIVE 01/01/2011)
QV — ITEM OR SERVICE PROVIDED AS ROUTINE CARE IN A MEDICARE QUALIFYING CLINICAL TRAIL (ENDS 12/31/2007)
GY — ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT (UPDATED 1/1/2008)
FB — ITEM PROVIDED W/O COST TO PROVIDER, SUPPLIER OR PRACTITIONER, OR FULL CREDIT RECEIVED FOR REPLACED DEVICE (UPDATED 1/1/2008)
QR — ITEM/SERVICE IN MEDICARE STUDY - OXYGEN (ENDS 12/31/2007)
T4 — LEFT FOOT, FIFTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T3 — LEFT FOOT, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
TA — LEFT FOOT, GREAT TOE (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T1 — LEFT FOOT, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T2 — LEFT FOOT, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
F3 — LEFT HAND, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F1 — LEFT HAND, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F2 — LEFT HAND, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
FA — LEFT HAND, THUMB (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
LT — LEFT SIDE. (USED TO IDENTIFY ITEM PROVIDED FOR THE LEFT SIDE OF THE BODY.)
N/A
K0 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 0
DOES NOT HAVE THE ABILITY OR POTENTIAL TO AMBULATE OR TRANSFER SAFELY WITH OR WITHOUT ASSISTANCE AND A PROSTHESIS DOES NOT ENHANCE THEIR QUALITY OF LIFE OR MOBILITY.
K1 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 1
HAS THE ABILITY OR POTENTIAL TO USE A PROSTHESIS FOR TRANSFERS OR AMBULATION ON LEVEL SURFACES AT FIXED CADENCE. TYPICAL OF THE LIMITED AND UNLIMITED HOUSEHOLD AMBULATOR.
K2 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 2
HAS THE ABILITY OR POTENTIAL FOR AMBULATION WITH THE ABILITY TO TRAVERSE LOW LEVEL ENVIRONMENTAL BARRIERS SUCH AS CURBS, STAIRS OR UNEVEN SURFACES. TYPICAL OF THE LIMITED COMMUNITY AMBULATOR.
K3 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 3
HAS THE ABILITY OR POTENTIAL FOR AMBULATION WITH VARIABLE CADENCE. TYPICAL OF THE COMMUNITY AMBULATOR WHO HAS THE ABILITY TO TRANSVERSE MOST ENVIRONMENTAL BARRIERS AND MAY HAVE VOCATIONAL, THERAPEUTIC OR EXERCISE ACTIVITY THAT DEMANDS PROSTHETIC UTILIZATION BEYOND SIMPLE LOCOMOTION.
K4 — LOWER PROSTHESIS FUNCTIONAL LEVEL 4
HAS THE ABILITY OR POTENTIAL FOR PROSTHETIC AMBULATION THAT EXCEEDS THE BASIC AMBULATION SKILLS, EXHIBITING HIGH IMPACT, STRESS, OR ENERGY LEVELS, TYPICAL OF THE PROSTHETIC DEMANDS OF THE CHILD, ACTIVE ADULT, OR ATHLETE.
SC — MEDICALLY NECESSARY SERVICE OR SUPPLY (EFFECTIVE DATE 01/01/2001)
GL — MEDICALLY UNNECESSARY UPGRADE PROVIDED INSTEAD OF NON-UPGRADED ITEM, NO CHARGE, NO ADVANCE BENEFICIARY NOTICE (ABN) (UPDATED 1/1/2008)
M2 — MEDICARE SECONDARY PAYER (MSP) (EFFECTIVE DATE 01/01/2007)
99 — MODIFIER OVERFLOW. (EFFECTIVE DATE 7/1/2003)
This modifier is used when you have exhausted the modifier field on the claim form. If you need additional room to add modifiers, append the 99 modifier to the last available field and include a narrative of other modifiers needed on the claim.
NB — NEBULIZER SYSTEM, ANY TYPE, FDA-CLEARED FOR USE WITH SPECIFIC DRUG (EFFECTIVE 01/01/2011)
NU — NEW DURABLE MEDICAL EQUIPMENT PURCHASE.
This modifier is used for new DME items that are purchased. When using the NU modifier, you are indicating you have furnished the beneficiary with a new (never used) piece of equipment.
NR — NEW WHEN RENTED
EY — NO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM OR SERVICE. (EFFECTIVE DATE 1/1/2003)
If you do not have a prescription from the physician prior to billing Medicare, you must append the EY modifier to your claim
GX — NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY (EFFECTIVE 04/01/2010)
ZA — NOVARTIS/SANDOZ
BO — ORALLY ADMINISTERED NUTRITION, NOT BY FEEDING TUBE. (EFFECTIVE DATE 1/1/2003)
When enteral nutrients (B4149-B4162) are administered by mouth, the BO modifier must be added to the code.
QH — OXYGEN CONSERVING DEVICE IS BEING USED WITH AN OXYGEN DELIVERY SYSTEM.
FC — PARTIAL CREDIT RECEIVED FOR REPLACED DEVICE (EFFECTIVE DATE 1/1/2008)
CG — POLICY CRITERIA APPLIED (EFFECTIVE DATE 07/01/2008)
Effective for claims with dates of service on or after July 1, 2010, if an L3923 orthosis has a rigid plastic or metal component, the supplier must add the CG modifier (policy criteria applied) to the code. Claims for L3923 billed without a CG modifier will be rejected as incorrect coding. The CG modifier must be added to code L0450, L0454, L0455, L0621, L0625, or L0628 only if it is one made primarily of nonelastic material (e.g., canvas, cotton or nylon) or having a rigid posterior panel.
QF — PRESCRIBED AMOUNT OF OXYGEN EXCEEDS 4 LPM AND PORTABLE OXYGEN IS PRESCRIBED.
These modifiers may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). They must not be used with codes for portable systems or oxygen contents.
QG — PRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN 4 LITERS PER MINUTE (LPM).
These modifiers may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). They must not be used with codes for portable systems or oxygen contents.
QE — PRESCRIBED AMOUNT OF OXYGEN IS LESS THAN 1 LITER PER MINUTE (LPM).
This modifier may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). They must not be used with codes for portable systems or oxygen contents
CC — PROCEDURE CODE CHANGE (USE 'CC' WHEN THE PROCEDURE CODE SUBMITTED WAS CHANGED EITHER FOR ADMINISTRATIVE REASONS OR BECAUSE AN INCORRECT CODE WAS FILED). (SUPPLIERS SHOULD NOT SUBMIT MODIFIER CC.)
PL — PROGRESSIVE ADDITION LENSES (EFFECTIVE DATE 01/01/89)
GK — REASONABLE AND NECESSARY ITEM/SERVICE ASSOCIATED WITH A GA OR GZ MODIFIER (UPDATED 1/1/2008)
KR — RENTAL ITEM, BILLING FOR PARTIAL MONTH.
RP — REPLACEMENT AND REPAIR. (DELETED EFFECTIVE 12/31/2008)
RP MAY BE USED TO INDICATE REPLACEMENT OF DME, ORTHOTIC AND PROSTHETIC DEVICES, WHICH HAVE BEEN IN USE FOR SOMETIME.
RA — REPLACEMENT OF A DME ITEM (EFFECTIVE 01/01/2009)
Claims for replacement of DME items should include the RA modifer for dates of service on or after January 1, 2009.
RB — REPLACEMENT OF A PART OF DME FURNISHED AS PART OF A REPAIR (EFFECTIVE 01/01/2009)
KM — REPLACEMENT OF FACIAL PROSTHESIS INCLUDING NEW IMPRESSION/MOULAGE
KN — REPLACEMENT OF FACIAL PROSTHESIS USING PREVIOUS MASTER MODEL
KC — REPLACEMENT OF SPECIAL POWER WHEELCHAIR INTERFACE. (EFFECTIVE DATE 01/01/05)
T9 — RIGHT FOOT, FIFTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T8 — RIGHT FOOT, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T5 — RIGHT FOOT, GREAT TOE (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T6 — RIGHT FOOT, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T7 — RIGHT FOOT, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
F9 — RIGHT HAND, FIFTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F8 — RIGHT HAND, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F6 — RIGHT HAND, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F7 — RIGHT HAND, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F5 — RIGHT HAND, THUMB (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
RT — RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY).
Q1 — ROUTINE CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN APPROVED CLINICAL RESEARCH STUDY (EFFECTIVE DATE 1/1/2008)
KQ — SECOND OR SUBSEQUENT DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION
When there is a single drug in a unit dose container, the KO modifier is added to the unit dose form code. (Exception: The KO modifier is not used with code J2545 or Q4080.) Except for code J7620, when two or more drugs are combined and dispensed to the patient in the same unit dose container, each of the drugs is billed using its unit dose form code. The KP modifier is added to only one of the unit dose form codes and the KQ modifier is added to the other unit dose code(s). Whenever a unit dose form code is billed, it must have a KO, KP or KQ modifier. (Exception: The KO, KP and KQ modifiers should not be used with code J7620.) If a unit dose code does not have one of these modifiers, it will be denied as an invalid code. The KO, KP, and KQ modifiers are not used with the concentrated form codes. The only FDA-approved unit dose preparation containing more than one drug is J7620, the combination of albuterol and ipratropium. Therefore, if the following FDA-approved unit dose codes are billed with a KP or KQ modifier, they will be rejected as invalid for claim submission: J2545, J7608, J7613, J7614, J7626, J7631, J7639, J7644, J7649, J7659, J7669, J7682, Q4080, and Q4080.
GW — SERVICE NOT RELATED TO THE HOSPICE PATIENT'S TERMINAL CONDITION. (USED FOR MEDICARE ADVANTAGE PLANS CLAIMS)
QJ — SERVICE/ITEMS PROVIDED TO A PRISONER OR PATIENT IN STATE OR LOCAL CUSTODY, HOWEVER THE STATE OR LOCAL GOVERNMENT, AS APPLICABLE, MEETS THE REQUIREMENT IN 42 CFR 411.1(B). (EFFECTIVE DATE 1/1/2003)