114.3 CMR 40.07 - Appendices

APPENDIX

DESCRIPTION

A

CPT and HCPCS Modifiers. Add the appropriate Level 1 CPT modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951. This table includes only common modifiers, any valid modifier may be used if it is appropriate to the situation.

B

Add-On Codes - Procedures that are commonly carried out in addition to the primary procedure performed and must never be reported as stand-alone codes. These codes are exempt from the multiple modifier '51' as are all codes that specify that they should be listed in addition to the main procedure.

C

Separate Procedures - Procedures that are stand alone codes. These codes are exempt from the multiple modifier '51'.

D

Drugs Administered Other Than Oral Method - List of drugs and biologicals that can be injected either subcutaneously, intramuscularly, or intravenously reimbursed at invoice cost.

APPENDIX A - Level I and Level II Common Modifiers This appendix lists the modifiers that are most commonly used in treating injured workers. The absence of a modifier from this appendix does not preclude its use in the appropriate situation.

(a) Anesthesia Modifiers.
1. Physical Status Modifiers. Physical status modifying units will be reimbursed if the patient is ranked in one of the following three categories. Physical status is included in CPT to distinguish various levels of complexity of the anesthesia service provided. Example: 00100-P3

Physical Status Modifiers

Description

Modifying Unit Value

P3

A patient with severe systemic disease.

1

P4

A patient with severe systemic disease that is a constant threat to life.

2

P5

A moribund patient who is not expected to survive without the operation.

3

2. CPT and HCPCS Modifiers for Anesthesia Services. Add the appropriate Level 1 CPT modifier or HCPCS Level II modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951.

Level 1 CPT Modifier

23 Unusual Anesthesia

Description

Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service.

47 Anesthesia by Surgeon

Regional or general anesthesia provided by the surgeon may be reported by adding the modifier '-47' to the basic service. (This does not include local anesthesia.) Note: Modifier '-47' or 09947 would not be used as a modifier for the anesthesia procedures.

AA Anesthesia services performed personally by anesthesiologist

This modifier must be used in conjunction with the appropriate service code to denote medical direction of one or two concurrent anesthesia procedures involving residents in a teaching environment. Payment for the physician's medical direction service shall be made at 100% of the allowance for the service performed by the physician alone.

QK Medical Direction of Multiple Anesthesia Procedures

This modifier must be used in conjunction with the appropriate service code to denote medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. Payment for the physician's medical direction service shall be made at 50% of the allowance for the service performed by the physician alone.

QX CRNA Service

This modifier must be used to report services of a CRNA: with medical direction by a physician. This medical direction modifier is used when the physician medically directs two, three, or four concurrent procedures involving interns, residents, CRNAs and AAs. This allows 50% of the fee to be paid to the employer.

QY CRNA Service

This modifier must be used to report medical direction of one CRNA by an anesthesiologist. This allows 50% of the fee to be paid to the employer.

QZ CRNA Service

This modifier is used to report CRNA service: without medical direction by a physician. This allows 100% of the fee to be paid to the employer.

(b) CPT Modifiers for Clinical Laboratory Services. Add the appropriate Level 1 or Level II CPT modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951.

Level 1 CPT Modifier

Description

-90 Reference (Outside) Laboratory

When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier '-90' to the usual procedure number.

-91 Repeat Clinical Diagnostic Laboratory Test

In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

(c) HCPCS Modifiers for Durable Medical Equipment, Oxygen Delivery and Orthotic and Prosthetic Procedure Codes. Add the appropriate Level II HCPCS modifier to the five-digit code to identify the specific circumstance.

Level II CPT Modifier

Description

KH

DMEPOS item, initial claim, purchase or first month rental

KI

DMEPOS item, second or third month rental

KJ

DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to 15

KM

Replacement of facial prosthesis including new impression/moulage

KN

Replacement of facial prosthesis using previous master model

KR

Rental Item, billing for partial month

LL

Lease/Rental (use the 'LL' modifier when DME equipment rental is to be applied against the purchase price)

MS

Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty

NR

New when rented (use the 'NR' modifier when DME which was new at the time of rental is subsequently purchased)

NU

New equipment

QE

Prescribed amount of oxygen is less than one liter per minute (LPM). This shall be reimbursed at 50% of the published rate of the appropriate service code.

QF

Prescribed amount of oxygen exceeds four liters per minute (LPM) and portable oxygen is prescribed. This shall be reimbursed at 150% of the published rate of the appropriate service code.

QG

Prescribed amount of oxygen is greater than four liters per minute (LPM). This shall be reimbursed at 150% of the published rate of the appropriate service code.

RP

Replacement and repair -RP may be used to indicate replacement of DME, orthotic and prosthetic devices which have been in use for sometime. The claim shows the code for the part, followed by the '-RP' modifier and the charge for the part

RR

Rental (use the 'RR' modifier when DME is to be rented)

UE

Used Durable Medical Equipment

(d) CPT and HCPCS Modifiers for Physicians' Services. Add the appropriate Level 1 CPT modifier or HCPCS Level II modifier to the five digit code.

Level 1 CPT Modifier

Description

21 Prolonged Evaluation and Management Services

When the face to face or floor/unit services(s) provided is prolonged or otherwise greater than that usually required for the highest level of evaluation and management service within a given category, it may be identified by adding modifier 21 to the evaluation and management code number. A report may also be appropriate

22 Unusual Procedural Service

When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required) Note: This modifier should not be appended to an E/M service.

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service

It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately indentifiable /M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date, This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. For significant, separately identifiable See non-E/M services, see modifier 59

26 Professional Component (PC)

Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding modifier -26 to the usual procedure number.

50 Bilateral Procedures

Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session, should be identified by adding modifier '50' to the appropriate five digit code. The addition of the modifier '50' to the second bilateral code allows 50% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the eligible provider for the second bilateral procedure.

51 Multiple Procedures

When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies(eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code. Note: This modifier should not be appended to designated "add-on" codes. The addition of the modifier 51 to the second and subsequent procedure code allows 50% of the allowable fee in 114.3 CMR 40.05 to be paid to the eligible provider.

52 Reduced Service

Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances, the service provided can be identified by its usual procedure number and addition of the modifier 52 signifying the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. The fee will be based on individual consideration.

54 Surgical Care Only

When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier 54 to the usual procedure number. This allows 85% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the surgeon.

55 Postoperative Management Only

When one physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the physician that provided the postoperative management.

59 Distinct Procedure or Service

If a procedure or service not normally reported together was performed on the same day, the fee will be based on the full maximum fee of 100% of the payment group for the distinct procedure or service.

62: Pertains to Two Surgeons

Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. These circumstances may be identified by adding the modifier 62 to the procedure code used by each surgeon for reporting his services. The addition of the modifier 62 to the procedure codes allows 57.5% of the allowable fee contained in 114.3 CMR 40.05 to be paid to each surgeon. No separate fee may be charged for assisting surgical services in these cases; it is included in the total surgical fee and may be paid to both physicians based upon their agreement.

66: Pertains to Team Surgery

Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of modifier 66 to the basic procedure number used for reporting services. Payment of each physician should be as agreed upon by the team and the insurer.

76 Repeat Procedure by the Same Physician

It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.

77 Repeat Procedure by Another Physician

The physician may need to indicate that a basic procedure or service performed by another physician has to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service.

78 Return to the Operating Room for a Related Procedure During the Postoperative Period

It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedure see modifier 76).

79 Unrelated Procedure or Service by the Same Physician during the Postoperative Period.

The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day see modifier 76).

80: Pertains to Assistant Surgeons

Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon.

81 Minimum Assistant Surgeon.

Minimum surgical assistant services are identified by adding the modifier 81 to the usual procedure number. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon.

82 Assistant Surgeon

(when qualified resident surgeon not available) The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code numbers. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon.

AS Assistant at Surgery

Physician assistant, nurse practitioner or clinical nurse specialist services for assistant at surgery.

SA Nurse Practitioner

Nurse practitioner rendering service in collaboration with a physician. This indicates reduced payment.

-SM Second Option

Second surgical opinion.

-SN Third Option

Third surgical opinion.

Appendix B - Add-On Codes Summary of CPT Add-On Codes for CPT 2008. Add on codes are identified in the CPT book with a "+".The CPT book is the final authority on the identification of add-on codes.

CODE

01953

15221

20937

26125

01968

15241

20938

26861

01969

15261

20985

26863

11001

15301

20986

27358

11008

15321

20987

27692

11101

15331

22103

31620

11201

15336

22116

31632

11732

15341

22208

31633

11922

15361

22216

31637

13102

15366

22226

32501

13122

15401

22328

33141

13133

15421

22522

33225

13153

15431

22525

33257

15003

15787

22527

33258

15005

15847

22534

33259

15101

16036

22585

33508

15111

17003

22614

33517

15116

17312

22632

33518

15121

17314

22840

33519

15131

17315

22841

33521

15136

19001

22842

33522

15151

19126

22843

33523

15152

19291

22844

33530

15156

19295

22845

33572

15157

19297

22846

33768

15171

20930

22847

33884

15176

20931

22848

33924

15201

20936

22851

33961

34806

61868

78480

99100

34808

62148

78496

99116

34813

62160

78730

99135

34826

63035

83901

99140

35306

63043

87187

99145

35390

63044

87904

99150

35400

63048

88155

99290

35500

63057

88185

99292

35572

63066

88311

99354

35600

63076

88312

99355

35681

63078

88313

99356

35682

63082

88314

99357

35683

63086

90466

99358

35685

63088

90468

99359

35686

63091

90472

99602

35697

63103

90474

99607

35700

63295

90761

36218

63308

90766

36248

64472

90767

36476

64476

90768

36479

64480

90770

37185

64484

90771

37186

64623

90775

37206

64627

90776

37208

64727

92547

37250

64778

92608

37251

64783

92627

38102

64787

92973

38746

64832

92974

38747

64837

92978

43635

64859

92979

44015

64872

92981

44121

64874

92984

44128

64876

92996

44139

64901

92998

44203

64902

93320

44213

66990

93321

44701

67225

93325

44955

67320

93571

47001

67331

93572

47550

67332

93609

48400

67334

93613

49326

67335

93621

49435

67340

93622

49568

69990

93623

49905

74301

93662

51797

75774

94645

56606

75946

95873

57267

75964

95874

58110

75968

95920

58611

75993

95962

59525

75996

95967

60512

76125

95973

61316

76802

95975

61517

76810

96411

61609

76812

96415

61610

76814

96417

61611

76937

96423

61612

77001

96570

61641

77051

96571

61642

77052

97546

61795

78020

97811

61864

78478

97814

APPENDIX C-- Codes Exempt from Modifier -51

Summary of CPT Separate Procedure Codes Exempt from Modifier 51 for CPT 2008. This list is not exhaustive. The CPT book identifies all codes exempt from modifier 51 and is the final authority on the matter.

CODE

17004

93539

93602

93631

20974

93540

93603

94610

20975

93544

93610

95900

31500

93545

93612

95903

36620

93555

93615

95904

44500

93556

93616

99143

61107

93600

93618

99144

93503

Appendix D: Drugs Administered Other Than Oral Method

CODE

J0476

J0770

J1270

J0120

J0480

J0780

J1300

J0128

J0500

J0795

J1320

J0129

J0515

J0800

J1325

J0130

J0520

J0835

J1325

J0132

J0530

J0850

J1327

J0133

J0540

J0878

J1330

J0150

J0550

J0881

J1335

J0152

J0560

J0882

J1364

J0170

J0570

J0885

J1380

J0180

J0580

J0886

J1390

J0190

J0583

J0894

J1410

J0200

J0585

J0895

J1430

J0205

J0587

J0900

J1435

J0207

J0592

J0945

J1436

J0210

J0594

J0970

J1438

J0215

J0595

J1000

J1440

J0220

J0600

J1020

J1441

J0256

J0610

J1030

J1450

J0270

J0620

J1040

J1451

J0275

J0630

J1051

J1452

J0278

J0636

J1055

J1455

J0280

J0637

J1056

J1457

J0282

J0640

J1060

J1457

J0285

J0670

J1070

J1460

J0287

J0690

J1080

J1470

J0288

J0692

J1094

J1480

J0289

J0694

J1100

J1490

J0290

J0696

J1110

J1500

J0295

J0697

J1120

J1510

J0300

J0698

J1160

J1520

J0330

J0702

J1162

J1530

J0348

J0704

J1165

J1540

J0350

J0706

J1170

J1550

J0360

J0710

J1180

J1560

J0364

J0713

J1190

J1561

J0365

J0715

J1200

J1562

J0380

J0720

J1205

J1565

J0390

J0725

J1212

J1566

J0395

J0735

J1230

J1568

J0400

J0740

J1240

J1569

J0456

J0743

J1245

J1570

J0460

J0744

J1250

J1571

J0470

J0745

J1260

J1572

J0475

J0760

J1265

J1573

J1580

J2270

J2805

J3487

J1590

J2271

J2810

J3488

J1595

J2275

J2820

J3490

J1600

J2278

J2850

J3520

J1610

J2280

J2910

J3530

J1620

J2300

J2916

J3535

J1626

J2310

J2920

J3570

J1630

J2315

J2930

J3590

J1631

J2320

J2940

J7030

J1640

J2321

J2941

J7040

J1642

J2322

J2950

J7042

J1644

J2325

J2993

J7050

J1645

J2353

J2995

J7060

J1650

J2354

J2997

J7070

J1652

J2355

J3000

J7100

J1655

J2357

J3010

J7110

J1670

J2360

J3030

J7120

J1700

J2370

J3070

J7130

J1710

J2400

J3100

J7187

J1720

J2405

J3105

J7189

J1730

J2410

J3110

J7190

J1740

J2425

J3120

J7191

J1742

J2430

J3130

J7192

J1743

J2440

J3140

J7193

J1745

J2460

J3150

J7194

J1751

J2469

J3230

J7195

J1752

J2501

J3240

J7197

J1756

J2503

J3243

J7198

J1785

J2504

J3246

J7199

J1790

J2505

J3250

J7300

J1800

J2510

J3260

J7302

J1810

J2513

J3265

J7303

J1815

J2515

J3280

J7304

J1817

J2540

J3285

J7306

J1825

J2543

J3301

J7307

J1830

J2545

J3302

J7308

J1835

J2550

J3303

J7310

J1840

J2560

J3305

J7311

J1850

J2590

J3310

J7321

J1885

J2597

J3315

J7322

J1890

J2650

J3320

J7323

J1931

J2670

J3350

J7324

J1940

J2675

J3355

J7330

J1945

J2680

J3360

J7340

J1950

J2690

J3364

J7341

J1955

J2700

J3365

J7342

J1956

J2710

J3370

J7343

J1960

J2720

J3395

J7344

J1980

J2724

J3396

J7346

J1990

J2725

J3400

J7347

J2001

J2730

J3410

J7348

J2010

J2760

J3411

J7349

J2020

J2765

J3415

J7500

J2060

J2770

J3420

J7501

J2150

J2778

J3430

J7502

J2170

J2780

J3465

J7504

J2175

J2783

J3470

J7505

J2180

J2788

J3472

J7506

J2185

J2790

J3473

J7507

J2210

J2791

J3475

J7509

J2248

J2792

J3480

J7510

J2250

J2795

J3485

J7511

J2260

J2800

J3486

J7513

J7515

J8520

J9212

J7516

J8521

J9213

J7517

J8530

J9214

J7518

J8540

J9215

J7520

J8560

J9216

J7525

J8565

J9217

J7599

J8597

J9218

J7602

J8600

J9219

J7603

J8610

J9225

J7604

J8650

J9226

J7605

J8700

J9230

J7607

J9000

J9245

J7608

J9001

J9250

J7609

J9010

J9260

J7610

J9015

J9261

J7615

J9017

J9263

J7620

J9020

J9264

J7622

J9025

J9265

J7624

J9027

J9266

J7626

J9031

J9268

J7627

J9035

J9270

J7629

J9040

J9280

J7631

J9041

J9290

J7632

J9045

J9291

J7633

J9050

J9293

J7634

J9055

J9300

J7635

J9060

J9303

J7636

J9062

J9305

J7637

J9065

J9310

J7638

J9070

J9320

J7639

J9080

J9340

J7640

J9090

J9350

J7641

J9091

J9355

J7642

J9092

J9357

J7643

J9093

J9360

J7644

J9094

J9370

J7645

J9095

J9375

J7647

J9096

J9380

J7648

J9097

J9390

J7649

J9098

J9395

J7650

J9100

J9600

J7658

J9110

J7659

J9120

J7660

J9130

J7667

J9140

J7668

J9150

J7669

J9151

J7670

J9160

J7674

J9165

J7676

J9170

J7680

J9175

J7681

J9178

J7682

J9181

J7683

J9182

J7684

J9185

J7685

J9190

J7699

J9200

J7799

J9201

J8498

J9202

J8499

J9206

J8501

J9208

J8510

J9209

J8515

J9211

Notes

114.3 CMR 40.07

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.


No prior version found.