Coding Billing Guidelines

  • Coding types and sources

  • Procedure coding used for the submission of a healthcare services claim consists of two industry standard coding systems:

    • CPT codes: The American Medical Association (AMA) updates and publishes the Current Procedural Terminology annually. The CPT lists descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. CPT Codes provide a uniform language that accurately designates medical, surgical, and diagnostic services-enabling reliable nationwide communication among physicians, patients, and third parties. You can order a CPT book by calling 800-621-8335.
    • HCPCS codes: The Centers for Medicare and Medicaid Services (CMS) maintains the Healthcare Common Procedure Coding System. HCPCS codes begin with a single letter (A through V) followed by four numbers. The codes are grouped by the type of service or supply they represent.

    When a CPT and a HCPCS code have very similar descriptions for a procedure or service, use the CPT code. If the code descriptions are not identical, select the code with the more specific description that reflects the service rendered.

    Select diagnosis coding from the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM).

    • The diagnosis code should be coded to the highest level of specificity/digits to accurately represent the medical condition.
    • The laterality identified in the Diagnosis code must not conflict with the laterality identified by the modifiers appended to the submitted procedure codes, and
    • Age banded diagnosis codes should be reflective of the age of the patient at the time the service was rendered.

    We abide by federal and state regulations concerning fraud, as well as our contract obligations to members and providers. To support this commitment, we have a Special Investigations Unit to prevent fraud and abuse. If you suspect fraud, call the Anti-Fraud Hotline at 800-848-0244.

    We apply the following claims coding guidelines:

    • We use Health Information Portability and Accountability Act (HIPAA) as the benchmark for accepting standard codes.
    • We accept one primary diagnosis code per line item (CMS-1500 form: box #21).
    • Each line item can have a different primary diagnosis or CPT code as long as that diagnosis is included in box #21 of the CMS-1500 form. The individual claim lines should be tagged with a specific diagnosis code, included in box #21 on the claim form.
    • We recognize standard modifiers.

    Because we cannot provide coding advice, we recommend that you maintain current copies of coding reference books or current versions of coding software in your office.

    We only reimburse current effective procedure codes in the CPT book published by the AMA and HCPCS Codes as maintained by CMS that are effective at the time of service in the year the service was rendered.

    If you submit a claim with a deleted code, it will be processed as a denial and the line item will indicate the corresponding denial code. Then you will need to correct the claim to reflect the appropriate code effective for the date of service on the claim and resubmit the claim as described in “Rebilling” below. Denied claims will be considered a physician or provider write-off until the corrected claim is processed.

    We use the following definitions established by the AMA and found in the current CPT codebook:

    • New patient: A person who has not received any professional service from a physician or other qualified healthcare practitioner or another physician of the same specialty in the same group practice within the past three years.
    • Established patient: A person who received professional services from the physician or other qualified healthcare practitioner or another physician of the same specialty in the same group practice within the past three years.

    We adopted a policy addressing the use of new and established patient evaluation and management codes. We rely on the physician or other qualified healthcare practitioner to use the code that most accurately reflects the service rendered. We may perform random audits to ensure services are billed appropriately per provider's documentation. As part of the audit process, we may request medical records supporting use of these codes.

  • Special billing situations

  • After-hours services (codes 99050 through 99060) are provided in the physician or provider’s office outside posted office hours, on Sundays, or on holidays. We don’t reimburse these codes, unless provider contract terms specifically include and allow reimbursement. These codes are Medicare Status B codes and are included in the allowance of another service(s).

    We use American Society of Anesthesiologists (ASA) codes (codes 00100-01999) to establish anesthesia base units. Use only ASA codes when billing anesthesia. Please note the following:

    • Anesthesia Modifiers: We require that the appropriate anesthesia modifier (modifiers AA, AD, QK, QX, QY, or QZ) be added to all anesthesia codes to identify the level of the provider rendering the service (e.g. Certified Registered Nurse Anesthetist, Resident Physician, supervising or directing Physician Anesthesiologist). Anesthesia codes submitted without an anesthesia modifier will be denied reimbursement.
    • Physical status modifiers: Additional time units are added for physical status modifiers P1-P6, based on the guidelines published annually in the ASA Relative Value Guide.
    • ASA codes 99100-99140 (Qualifying Circumstance codes): These codes are Medicare Status B services and are not be eligible for reimbursement.
    • ASA add-on codes: These codes are reimbursed based on guidelines published annually in the Relative Value Guide from the ASA and must be billed in conjunction with the base anesthesia code.
    • Obstetrical anesthesia: We allow standard base units for obstetrical delivery of epidural anesthesia.
    • Labor management anesthesia: We allow three time units for labor management for the initial hour and two time units for each additional hour.
    • Conversion of time to units: Anesthesia units are calculated based on a four-unit hour. We convert reported anesthesia time to units by dividing the total anesthesia minutes reported by 15 and standard rounding to the nearest hundredth decimal point (example: 4.33).
    • Nerve blocks: We reimburse nerve blocks based on Relative Value Units only.
    • Moderate Sedation: Moderate sedation provided by a physician or other qualified healthcare professional that is also performing the surgical procedure would be billed using codes 99151, 99152, and 99153. Use codes 99155, 99156, and 99157 to bill for moderate sedation provided by a physician or other qualified healthcare professional who's not performing the surgical procedure.

    We limit blood draws (36415) to one per provider, per patient, per day. We’ll deny CPT code 36416 as a Medicare Status B code.

    All hospital outpatient facility services billed with revenue codes 0760 – 0769 (outpatient treatment/observation room) are processed subject to the hospital outpatient facility medical benefit cost shares. You must bill hospital outpatient facility surgical services with revenue codes 0360, 0361, 0369, 0490-0499, or 0750 and the appropriate surgical CPT procedure code in order to be subject to the hospital outpatient facility surgical benefit cost shares.

    Outpatient facility diagnostic services will apply to the diagnostic services benefit when not impacted by a pricing mechanism that packages or bundles based on a procedure.

    All other outpatient facility service (except diagnostic) will apply toward the applicable services benefit (i.e. surgical services, rehab, ER, etc.), when not impacted by a pricing mechanism that packages or bundles based on a procedure.

    A locum tenens physician does not need to be credentialed because he/she is considered a temporary provider; however, if a locum tenens physician provides services for more than 90 days, he/she must be credentialed. A locum tenens physician bills under the name of the absent, contracted physician appending modifier Q6 to all services rendered.

    Twins-Both Vaginal or One Vaginal and One Cesarean

    We'll reimburse one global obstetric birthing procedure (routine prenatal obstetric care, delivery, and postpartum care) for the first birth and one delivery-only procedure for the second birth. Note that the level of reimbursement is subject to our payment policy on multiple procedures.

    Example 1:
    59400 - allowed at 100 percent

    Example 2:
    59400 - allowed at 100 percent
    59514-59 - allowed at 50 percent
    59409-59 - allowed at 50 percent

    Twins-both cesarean

    We reimburse either one global obstetric birthing procedure (routine prenatal obstetric care, delivery, and post-partum care) or one delivery-only procedure, whichever is appropriate.

    Example:
    59510 - allowed at 100 percent
    59514-59 - no additional reimbursement

    Triplets, quadruplets, etc-All Cesarean

    We reimburse one global obstetric birthing procedure (routine prenatal obstetric care, delivery, and post-partum care).

    Example:
    59510 - allowed at 100 percent
    59514-59 - no additional reimbursement
    59514-59 - no additional reimbursement

    Bill the delivery of each baby on a separate line on the claim. Each subsequent birth after the initial birth should be billed with modifier 59-Distinct Procedural Service in order to prevent an edit indicating a duplicate service.

    Osteopathic manipulation is a form of manual treatment applied by a physician to eliminate or alleviate somatic dysfunction and related disorders. Please note the following:

    • Osteopathic manipulation code billed with a new patient E/M code: both allowed at 100 percent of the allowable charge.
    • Osteopathic manipulation code billed with an established patient E/M code: only the manipulation is allowed at 100 percent of the allowable charge. If the E/M service is separate and distinct from the manipulation, the E/M should be reported with a modifier 25. Documentation in the member’s medical record must support that the evaluation and management services was truly distinct and separate from the surgical procedure performed.
    • Only one osteopathic manipulation code (codes 98925 – 98929), per day, per member is allowed.
    • Physical therapy service codes billed with an osteopathic manipulation code will allow each service: both allowed at 100 percent of the allowable charge. Reimbursement of multiple physical therapy services is consistent with our policy on physical therapy services limits.

    Evaluation and management services provided the date before or on the date of a major surgical procedure will be considered part of the global surgery reimbursement and are not eligible for separate reimbursement. If the visit resulted in the initial decision to perform surgery separate reimbursement will be allowed for the evaluation and management service when appended with Modifier 57.

    For significant, separately identifiable and documented E/M services billed on the same day as a surgical procedure, use modifier 25 on the evaluation and management service to indicate the service was a distinct procedural service from the surgical procedure. Documentation in the member’s medical record must support that the evaluation and management services was truly distinct and separate from the surgical procedure performed.

    We’ll allow separate reimbursement for an E/M service as a visit on the same day as a screening Pap smear (Q0091) when the E/M visit is a separate and distinct service from the Pap smear and is reported with modifier 25. Documentation in the member’s medical record must support that the evaluation and management services was truly distinct and separate from the procedure performed. Separate reimbursement is not allowed for a screening Pap smear (Q0091) when performed on the same day as a preventive medicine examination or annual gynecological examination.

    We have payment policies that define how to use Modifiers -80, -81, -82 and -AS to indicate when surgical assistance is provided to a primary surgeon. Bill all surgical assistance services under the name of the performing provider or the person who assisted the primary surgeon. Bill the charges for the primary surgeon and the assisting surgeon on separate claims

    Modifier -80, Assistant Surgeon. This modifier indicates that the assisting surgeon is actively assisting a primary surgeon. Add Modifier -80 to the surgical procedure to identify surgical assistant services when appropriate. Only one physician may assist another physician in performing a procedure. If an assistant surgeon assists a primary surgeon and is present for the entire operation, then the assisting physician reports the same surgical procedure as the primary surgeon with Modifier -80 appended. Modifier 80 and modifier AS can't be billed on the same claim by the same provider.

    Modifier -81, Minimum Assistant Surgeon. This modifier is used when the surgical assistant does not participate in the entire surgical procedure. Add Modifier -81 to the surgical procedure to identify minimum surgical assistant services when appropriate. There are times when a primary operating physician may plan to perform a surgical procedure alone, but during the operation, circumstances may require surgical assistance for a relatively short time. In this instance, the second surgeon provides minimal assistance, for which he/she reports the same surgical procedure as the operating surgeon with Modifier -81 appended. Modifier 81 and modifier AS can't be billed on the same claim by the same provider.

    Modifier -82, Assistant Surgeon (when qualified resident surgeon is not available). The prerequisite for adding Modifier -82 to the surgical procedure is the unavailability of a qualified resident surgeon. In certain programs (e.g., teaching hospital), the physician acting as the assistant surgeon is usually a qualified resident surgeon. However, there may be times (e.g., during rotation change) when a qualified resident surgeon is not available and another surgeon assists in the operation. In this instance, the services of the nonresident-assistant surgeon should be reported with Modifier -82 appended to the appropriate code to show that another surgeon assisted the operating surgeon instead of a qualified resident surgeon. Modifier 82 and modifier AS can't be billed on the same claim by the same provider.

    Modifier -AS. PA, NP, or clinical nurse specialist services for assistant at surgery. This modifier is used when a “non-physician” provider assists the primary surgeon. Use this modifier when a PA, NP, or clinical nurse specialist provides surgical assistance. Add the HCPCS modifier -AS to the same surgical procedure code as the primary surgeon. Modifier AS and modifiers 80, 81, or 82 can't be billed on the same claim by the same provider.

    Telehealth services are described as medical information exchanged from one site to another via electronic modes of communication between a practitioner and patient in a manner other than an in office face-to-face encounter. Such services can be delivered via:

    Real-Time or Near Real-Time Interactive or Synchronous Technology include systems that transmit interactive audio and video information and permit two-way, real-time communication instantly or with very little or no noticeable delay. The patient must be present and participating in the telehealth visit (Example: a videoconference).

    Store-and-Forward or Asynchronous technology uses high-resolution video and high-fidelity audio to transmit information that will be stored and sent to a practitioner in a distant site for interpretation at a later time. The patient is not present and is not participating in the visit.

    Asynchronous communications do not  include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (email).

    Telephone Assessment and Management are a non-face to face E/M provided to a patient using a telephone by a physician or other non-physician healthcare professional who may report E/M services. The encounter is the equivalent of a low-level office visit with all of the same history, exam and medical decision making criteria documented in the member's medical record. Such encounters are not used for renewing prescriptions or triaging a patient in order to set up an office visit within 24 hours.

    Online/Internet Communications are a non-face to face E/M provided by a physician or other qualified non-physician healthcare professional who may report E/M services using a secure and encrypted Internet resource in response to a patient's online inquiry. Such encounters include all of the provider's personal time in response to the patient and involve permanent storage (electronic or hard copy) of the encounter. This encounter is the equivalent of a low level office visit with all of the same history, exam, and medical decision making criteria documented in the member's medical record.

    Synchronous and Asynchronous technology requires specifying both an originating site and a distant site. Each site would submit a separate claim for their services. These sites are defined as follows:

    • Distant site: The location from which the physician or practitioner providing the professional medical service is located at the time the telehealth service is provided.
    • Originating site: The location of the insured patient at the time the telehealth service is performed.

    Note the following:

    • We recognize the use of synchronous or asynchronous communications substituted for a face-to-face, hands-on encounter for consultation services, office visits, individual psychotherapy services, and pharmacologic management services when appended with the appropriate modifie.
    • We require modifiers 95-Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system, GQ-Via asynchronous telecommunications system, or GT-Via interactive audio and video telecommunication systems to be used to indicate that the services were provided using a telecommunications system. By using one of these modifiers, the distant site practitioner verifies that the patient was located at an eligible originating site at the time of the telehealth service.
    • We recognize HCPCS Code Q3014-Telehealth originating site facility fee (without any modifier) as the code designated to indicate the originating facility fee. This code cannot be billed by the “distant site” provider.
    • We require documentation in the member's record to support any encounter conducted as a synchronous office visit, a telephone assessment or an online/internet communication, and that it be made available for review in the event of an audit.

    We do not reimburse for professional services or supplies that are usually provided free because of the relationship to the patient.

    As a reminder, physicians, providers or suppliers who are our members are not reimbursed by us for professional services for any of the following when services are

    • Performed on themselves
    • Rendered to family members residing in the home
    • Provided to the following immediate relatives: spouse, natural or adoptive parent, child, sibling, stepparent, stepchild, stepsibling, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, grandparent, grandchild, spouse of grandparent, or spouse of a grandchild

    An ARNP or NP provides services to members via one of the following methods:

    • Clinic practice: bills under the name of a contracted, supervising physician-credentialing not required (a clinic can be one or more physicians)
    • Solo ARNP: bills under his/her own name (credentialing required)
    • Surgical assistant ARNP: bills under his/her own name (must complete a Data Request form prior to performing services)

    A PA provides services to members via one of the following methods:

    • Clinic practice: bills under the name of a contracted, supervising physician-credentialing not applicable to Pas (a clinic can be one or more physicians)
    • Surgical assistant PA: bills under his/her own name (must complete a Data Request form prior to performing services is required).

    Some procedures in the CPT codebook are performed in addition to a primary service code. These services are notated as an add-on code by the symbol “ + “ in the codebook and are listed in Appendix D of the CPT Codebook. Add-on codes are always performed in conjunction with a primary code/procedure. Instructions identifying the correct primary code are listed after the add-on code in the CPT codebook.

    Healthcare professionals may render procedures and services for which there is no specific CPT or HCPCS code available. Providers may use unlisted codes, unspecified codes, or miscellaneous codes, which usually end in XXX99. These codes don’t have specific language that describes the particular service. These codes should only be used as a last resort if there is not a more specific CPT or HCPCS code available.

    We require that you submit supporting detailed documentation with claims to describe the service(s) rendered, identifying what was performed as part of the service. Critical documentation should include:

    • A clear description of the service performed
    • Identification as to whether the service performed was independent form other services performed at the same time
    • Any extenuating circumstances which may have complicated the service
    • Time, effort and equipment necessary to provide the service, and
    • Number of times this service has been performed

    Failure to provide such detailed information will result in a delay or denial of the claim being processed.

    All unlisted, non-specific, and miscellaneous CPT and HCPCS codes submitted on a claim, along with the supporting documentation described above, will be subject to clinical review at claims submission. Premera does not review unlisted, non-specific or miscellaneous CPT and HCPCS codes prior to service delivery; this subset of codes is not subject to prior authorization. During the review of each submitted unlisted, non-specific, or miscellaneous code, Premera will determine how that code will be priced (e.g. such as but not limited to basing on a comparable code, a comparable code with modifier 22 added, or on a percentage of charge) as part of the processing of the entire claim.

    In the National Physician Fee Schedule (NPFS), as maintained by CMS, procedure codes that are identified with a Status Indicator code of B are not eligible for reimbursement, whether billed alone or with another service, and will be denied. To obtain a complete list of Status B codes, visit the CMS website and select the most current NPFS release.

    We restrict the use of these prolonged service codes in maternity care. We don’t provide reimbursement separately when prolonged service codes are billed to indicate the management of labor, which is considered a component of the delivery care.

    Prolonged services for both outpatient and inpatient care are billed using the following codes:

    • +99354 – Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour. (List separately in addition to code for office or other outpatient Evaluation and Management service.)
    • +99355 – each additional 30 minutes. (List separately in addition to code for prolonged service.)
    • +99356 – Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour. (List separately in addition to code for inpatient Evaluation and Management service.)
    • +99357 – each additional 30 minutes. (List separately in addition to code for prolonged service.)
      “+” denotes an add-on code

    Global surgery or global surgical package is a period of time that starts either with the day of or the day before the surgical procedure. It ends some timeframe after the surgical procedure based on whether the procedure is classified as minor or major surgery.

    We use the global surgery indicator flag as established in the current version of the National Physician Fee Schedule (NPFS), maintained by CMS, to determine whether a procedure code does/doesn’t have a specified global surgery period (e.g., simple/minor procedures, minor surgical procedures, major surgical procedures, maternity codes, global periods to not apply, carrier/plan determined or add-on codes).

    Robotic surgery and computer-assisted navigation services are add-on techniques used to perform the main surgical procedure. As such, when these add-on codes are billed , the robotic surgical system code and the computer-assisted navigation codes will be considered bundled/included as part of the primary surgical procedure. They aren’t separately reimbursable, whether billed separately or in conjunction with a primary procedure.

    Robotic surgical system services and computer-assisted navigation for musculoskeletal surgical services are billed using the following HCPCS or CPT codes:

    • +S2900 – Surgical techniques requiring use of robotic surgical system. (List separately in addition to code for primary procedure.)
    • +20985 – Computer assisted surgical navigational procedure for musculoskeletal procedures, image-less. (List separately in addition to code for primary procedure.)
    • +0054T – Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images. (List separately in addition to code for primary procedure.)
    • +0055T – Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on CT/MRI images. (List separately in addition to code for primary procedure.)
      “+”denotes an add-on code which must be billed with an appropriate primary procedure

    When administering drugs from a single use vial or package, a leftover portion of the drug that wasn't administered to a patient can be submitted for reimbursement. Include the administered portion of the drug.

    Submit two lines with the same HCPCS or CPT code, one line with the modifier JW to represent the non-administered portion and the other line without the modifier to represent the administered portion. Units on each line should represent the portions administered and the portion non-administered or wasted.

    Modifiers are required on any piece of DME that can be rented to own, whether that is a daily rental, a monthly rental, or a continuous rental of the equipment. Add one of the following modifiers to reflect whether the equipment is either a purchased, replacement or rented piece of equipment:

    • Purchase modifiers
      • NU - new equipment
      • NR - new when rented. (Use when DME that was new when first rented is later purchased. Bill the purchase price of the equipment.)
      • RA - replacement of a DME, orthotic or prosthetic item
      • UE - used DME
    • Rental modifiers
      • RR - rental
      • LL - Lease/rental
      • KR - rental item for a partial month. (Use to indicate daily rentals.)

    Units of service must also match the type of DME rental in order to be correctly reimbursed:

    • Monthly rentals
      • One month of rental equals one unit when modifier RR is added.
      • Each month should be billed on a single claim line (i.e. 1 service month rather than 30 units of service).
    • Daily rentals
      • One day of rental equals one unit when modifier KR is appended.
      • “From” and “Through” dates of service must match the number of unit billed.
      • Future dates of service will not be accepted; submit claims after the end of the rental period.

    All related diagnostic and non-diagnostic services (preadmission testing) provided by an admitting hospital on the date of an inpatient admission or within 3 calendar days preceding the date of an inpatient admission are considered to be part of/incidental to the inpatient admission hospital claim. These services aren't separately billable or reimbursable. Related services rendered within the 3-calendar day window must be billed on the same claim as the inpatient admission.

    Any services rendered within the 3-calendar day window that are not related to a planned inpatient admission must be identified on the UB-04 claim form as being unrelated by using Condition Code 51-Attestation of Unrelated Outpatient Non-diagnostic Services in Field Locator 18-28.

    Any services rendered on the date of an unplanned inpatient admission as part of an emergency room visit that led to the unplanned inpatient admission should be included on the inpatient admission claim. Such an unplanned emergency inpatient admission should be identified using Admission Type Code 1-Emergency in Field Locator 14 of the UB-04 claim form.

    Emergency room visits that occur within three calendar days prior to an inpatient admission that are diagnostically related to the inpatient admission will be considered part of the inpatient admission. These visits are denied separate reimbursement.

    Exclusions

    • Ambulance services
    • Maintenance renal dialysis
    • Chemotherapy
    • Outpatient surgery
    • Radiation Therapy
    • Blood/RX products
    • Physical, Occupational, and Speech therapies
  • Modifiers

  • The use of modifiers is an important component to coding and billing for services. A modifier is a two-digit character (numeric, alpha numeric, or alpha) designed to provide additional information needed to process a claim or increase or decrease reimbursement. Modifiers allow a provider to identify that a special circumstance has altered a service, but that the basic procedure code description has not changed. Appropriately document the patient’s medical record or chart to support the use of any modifier.

    In certain circumstances, multiple modifiers may be necessary to completely describe a service. Our payment system recognizes multiple modifiers to allow you to bill up to four separate modifiers per claim line.

    When more than 4 modifiers are needed for a service, modifier 99-Multiple Modifiers should be used to reflect this situation. Make sure that documentation in the member’s medical record supports all of the modifiers submitted.

  • Most Commonly Used Modifiers

    We process the following modifiers when appended to an appropriate code(s). Where applicable, the provider's fee schedule allowed amount will be adjusted per any percentage noted:

    Code Brief description of modifier Reimbursement adjustment
    percentage
    Applicable code categories
    22 Increased procedural service 125% Surgery, radiology, pathology and laboratory, medicine
    23 Unusual anesthesia   Anesthesia
    24 Unrelated evaluation and management (E/M) service by same physician or other qualified healthcare professional during a postoperative period   E/M
    25 Significant, separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or other service   E/M
    26 Professional component: for use in the reporting when only the professional component of a procedure is provided   Surgery, radiology, pathology and laboratory, medicine
    27* Multiple outpatient (OP) hospital E/M encounters on same day   E/M
    32 Mandated service   E/M, c, surgery, radiology, pathology and laboratory, medicine
    33 Preventive service   E/M, radiology, pathology and laboratory, medicine
    47 Anesthesia by surgeon   Surgery
    50 Bilateral procedure 150% Surgery, radiology, medicine
    51 Multiple procedures   Surgery, medicine
    52 Reduced services 75% Surgery, radiology, pathology and laboratory, medicine
    53 Discontinued service 33%  
    54 Surgical care only 70% Surgery
    55 Postoperative management only 20% Surgery, medicine
    56 Preoperative management only 10% Surgery, medicine
    57 Decision for surgery   E/M
    58 Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period   Surgery, radiology, medicine
    59 Distinct procedural service   Surgery, radiology, pathology, and laboratory, medicine
    62 Two surgeons 62.5% Surgery
    63 Procedure performed on infants less than 4kg   Surgery
    66 Surgical team   Surgery
    73* Discounted OP/ambulatory surgery center (ASC procedure) prior to anesthesia administration 50% Anesthesia, surgery, radiology, pathology and laboratory
    74* Discontinued OP/ASC procedure after administration of anesthesia   Anesthesia, surgery, radiology, pathology and laboratory
    76 Repeat procedure by same physician or other qualified healthcare professional   Surgery, radiology, medicine
    77 Repeat procedure by another physician or other qualified healthcare professional   Surgery, radiology, medicine
    78 Unplanned return to the operating room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period 78% Surgery, medicine
    79 Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period   Surgery, medicine
    80 Assistant surgeon 20% Surgery
    81 Minimum assistant surgeon 10% Surgery
    82 Assistant surgeon (when qualified resident surgeon not available) 20% Surgery
    90 Reference (outside) laboratory   Pathology and laboratory
    91 Repeat clinical diagnostic laboratory test   Pathology and laboratory
    92 Alternative lab platform testing   Pathology and laboratory
    99 Multiple modifiers   Surgery, radiology, medicine
    AA Anesthesia performed personally by anesthesiologist   Anesthesia
    AD Medical supervision by a physician; more than four concurrent anesthesia procedures 50% Anesthesia
    AS Physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist services for assistant-at-surgeon 10% Surgery
    GA Waiver of Liability Issued as required by Payer Policy   E/M, surgery, radiology, laboratory, medicine, HCPCS
    GQ Telehealth services via asynchronous telecommunications system   E/M, medicine, HCPCS
    GT Telehealth services via interactive audio and video telecommunications systems   E/M, medicine, HCPCS
    JW Drug amount discarded/not administered to any patient   HCPCS, medicine
    KX Requirements specified in the Medical Policy have been met   HCPCS
    NR New Durable Medical Equipment when rented   HCPCS
    NU New Durable Medical Equipment   HCPCS
    QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals 50% Anesthesia
    QS Monitored anesthesia care   Anesthesia
    QX CRNA service with medical direction by a physician 50% Anesthesia
    QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist 50%  Anesthesia
    QZ CRNA service without medical direction by a physician   Anesthesia
    RA Replacement of Durable Medical Equipment, Orthotic or Prosthetic item   HCPCS
    RR Durable Medical Equipment-Rental   HCPCS
    SG ASC facility service   ACS and Birthing Center services only
    SL State Supplied Vaccine   Medicine
    SU Procedure performed in Physician's Office (facility and equipment   Surgery, medicine, HCPS
    TC Technical component: for use in reporting when only the technical component of a procedure is provided   Radiology, pathology, medicine
    TH Obstetrical treatment/services   E/M
    XE Separate encounter, a service that is distinct because it occurred during a separate encounter   Anesthesia, surgery, radiology, pathology and laboratory, medicine
    XP Separate practitioner, a service that is distinct because it was performed by a different practitioner   Anesthesia, surgery, radiology, pathology and laboratory, medicine
    XS Separate structure, a service that is distinct because it was performed on a separate organ/structure   Surgery, radiology, medicine
    XU Unusual non-overlapping service, the use of a service, the use of a service that is distinct because it does not overlap usual components of the main service   Surgery, radiology, pathology and laboratory, medicine

    *Outpatient and ambulatory surgery center use only

    If you have a question regarding a code modifier combination, use the Claims Editor What If Tool under Tools.

  • NDC code billing guidelines

    For any provider administered or supplied drug or vaccine submitted on an electronic or paper claim, a National Drug Code (NDC) number, an NDC units/basis of measure, and NDC units must be submitted along with an appropriate HCPCS or CPT code on the same claim line. The appropriate NDC number can be found on the drug label or outer packaging and should be 11 digits in length. Failure to supply an NDC number may result in a denial of the claim line.

    A NDC code number is an 11-digit number in a 5-4-2 digit format that is assigned to each medication approved by the Food and Drug Administration. The three segments in the number, NNNNN-NNNN-NN, indicate the following:

    • First segment - Identifies the company that manufactures or distributes the drug (assigned by the Food and Drug Administration)
    • Second segment - Identifies the product, its specific strength, dosage form, and formulation of a drug (assigned by the drug manufacturer)
    • Third segment - Identifies the package size and type (assigned by the drug manufacturer)

    How to submit an NDC number on a claim

    Some general guidelines to help in the submission of an NDC drug code include:

    • Submit an NDC code along with the appropriate HCPCS or CPT drug code and the number of HCPCS/CPT drug code units
    • NDC code must follow the 11 digit billing format with no spaces, hyphens or special characters in the number
    • The NDC code must be active for the date of service submitted
    • The NDC code must include the Product ID Qualifier, the NDC unit/basis of measurement, and the number of NDC Units

    Professional Claims:

    1) Electronic Claim Guidelines (ANSI 837P)

    Field Name Field Description Loop ID Segment/ Element
    Product ID Qualifier Enter N4 in this field 2410 LIN02
    National Drug Code number Enter the 11 digit NDC billing format assigned to the drug administered 2410 LIN03
    National Drug Unit Count Enter the quantity (number of NDC Units) 2410 CPT04
    Unit/basis of measurement Enter the NDC unit/basis of measurement for the prescription drug given (UN, ME, ML, DR, F2) 2410 CPT05

    2) Paper Claim Guidelines (CMS-1500)

    The CMS-1500 claim form allows for the submission of one NDC code per HCPCS/CPT drug code line submitted. The HCPCS/CPT drug code is submitted on the lower portion (unshaded portion) of the claim line and the NDC code is billed on the upper portion (shaded portion) of the same line (see example below).

    In the shaded portion/upper portion of the line, item field 24 on the CMS-1500, enter the following:

    • qualifier N4 (left-justified)
    • the NDC number (11 digits, no spaces, include the leading zeroes)
    • one space for separation, then enter the appropriate qualifier for the correct dispensing unit/basis of measurement (UN, ME, ML, GR, or F2), followed by the quantity (number of NDC units up to eight digits before the decimal and up to three digits after the decimal), as indicated in the example below.

    NDC code

    Facility Claims:

    3) Electronic Claim Guidelines (ANSI 8371)

    Field Name Field Description Loop ID Segment/ Element
    Product or Service ID Qualifier Enter N4 in this field 2410 LIN02
    National Drug Code number Enter the 11 digit NDC billing format assigned to the drug administered 2410 LIN03
    National Drug Unit Count Enter the quantity for the NDC billed (number of NDC Units) 2410 CPT04
    Unit/basis of measurement Enter the NDC unit/basis of measurement for the prescription drug given
    • UN - Unit
    • ME - Milligram
    • ML - Milliliter
    • GR - Gram
    • F2 - International Unit
    2410 CPT05-01

    4) Paper Claim Guidelines (UB-04/CMS-1450)

    On the UB-04/CMS-1450 claim form, each drug administered in the hospital/facility setting is required to be submitted on an individual line with an appropriate Revenue Code (Field 42). Each drug code line must include the NDC drug code (Field 43, left justified), the applicable CPT or HCPCS code (Field 44), date of service (Field 45), CPT/HCPCS code units (Field 46) and a charge for the drug supplied/administered (Field 47).

    UB-04/CMS-1450 Claim Example:

    Field 42 - REVENUE CODE - insert the appropriate code (ex. 0636, 0250)

    Field 43: DESCRIPTION - Insert the NDC code along with the following information:

    • First 2 digits: NDC Qualifier = N4
    • Next 11 digits: NDC Number 12345678901
    • Next 2 digits: Unit of measurement qualifier
      • F2-International Units;
      • GR-Gram;
      • ML-Milliliter;
      • ME-Milligram;
      • UN-Units)
    • Final digits: Unit quantity for the NDC drug, not the CPT or HCPCS drug code units (max 4 digits before decimal and max 3 digits after decimal)

    UB-04-claim-example

    Field 45: SERV DATE - Date of service

    Field 46: SERV UNITS - HCPCS code units (not the units for the NDC but units associated with the dosage for the HCPCS code)

    Field 47: TOTAL CHARGES - Charge

    If billing for a compound drug, each specific drug in the compound must be billed on a separate line with the appropriate HCPCS/CPT drug code, the corresponding Product ID Qualifier, the NDC number, unit/basis of measurement and NDC units.

    Failure to include an NDC# in the format described above along with the billed drug CPT or HCPCS code will result in a denial of reimbursement of the claim.

    Reimbursement for discarded/non-administered drugs applies only to single-use vials. Multi-use vials are not subject to payment for discarded amount of the drug. Append modifier JW to the discarded drug line only.