Modifiers

Effective January 1, 2017, providers are required to use HCPCS modifier JW for claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals).

Providers are also required to document the discarded drug or biological in the patient's medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded. For more information, see our article HCPCS Modifier JW.

Resource: MM9603 (PDF).

Last Reviewed: 9/18/2024

No, multi-use vials are not subject to payment for discarded amounts of drugs or biologicals. For more information, see our article HCPCS Modifier JW.

Resource: CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40 — Discarded Drugs and Biologicals (PDF).

Last Reviewed: 9/18/2024

Yes. Documentation modifiers must be submitted in the first position. The appropriate modifier from the list below must be submitted in the first position to indicate whether the service was personally performed, medically directed or medically supervised:

• AA — Anesthesia services performed personally by an anesthesiologist
• QK — Medical direction by a physician of two, three, or four concurrent anesthesia procedures
• AD — Medically supervised by a physician, more than four concurrent anesthesia procedures
• QY — Medical direction of one CRNA/AA (Anesthesiologist's Assistant) by an anesthesiologist
• QX — CRNA/AA (Anesthesiologist's Assistant) service with medical direction by a physician
• QZ — CRNA/AA (Anesthesiologist's Assistant) service without medical direction by a physician

If one of the following monitored anesthesia modifiers applies, it must be submitted as an additional modifier in the second position: 

• QS — Monitored anesthesia care service
• G8 — Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures
• G9 — Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition

Processing delays and rejections may occur for claims submitted without the modifiers in the correct position.

Resource: CMS IOM Pub. 100-04, Chapter 12, Section 50 (PDF).

Last Reviewed: 9/18/2024

Yes. The Multi-Carrier System (MCS) used for claims processing requires placement of pricing modifiers in the first modifier position to process claims correctly.

Processing delays or rejections can occur for claims submitted without the pricing modifier in the first modifier position.

* These payment modifiers are not limited to the first position. (If there is another pricing modifier submitted that is required to be in the first modifier field, these modifiers should be in the second, third or fourth modifier position.)

Last Reviewed: 9/18/2024

The units of service you should submit depends on the Medicare Physician Fee Schedule bilateral indicator assigned to the procedure code. 

• If you are billing a bilateral surgical procedure, having a BILAT indicator of 1, you must submit CPT® modifier 50, with 1 in the Quantity Billed field. Any other combination may result in a denial or an under payment.
• If you are billing a bilateral procedure, having a BILAT indicator of 2, CPT® modifier 50 or anatomic HCPCS modifiers (e.g., RT, LT, FA, F1–F9, TA, T1–T9, E1–E4), should not be submitted. These codes are considered bilateral and/or the code descriptions include possible multiple services. Any combination of these modifiers may result in a denial.
• If you are billing a bilateral procedure, having a BILAT indicator of 3, CPT® modifier 50 and anatomic HCPCS modifiers (e.g., RT, LT, FA, F1–F9, TA, T1–T9, E1–E4) may be submitted with the number of services performed indicated by utilizing the Quantity Billed field as appropriate

Refer to the payment policy indicators on the CMS Medicare Physician Fee Schedule Database (MFSDB) to determine the bilateral (BILAT) indicator. Access the MFSDB directly from the CMS website.

Last Reviewed: 9/18/2024

No. CPT® modifier 51 is a system-generated modifier. It is used to ensure multiple surgeries submitted for a patient with the same date of service are reimbursed correctly. We ask that providers not use this modifier.

Last Reviewed: 9/18/2024

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for professional services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an independent attending physician, who is not an employee of the designated hospice nor receives compensation from the hospice for those services. For purposes of administering the hospice benefit provisions, an "attending physician" means an individual who:

• Is a doctor of medicine or osteopathy or a nurse practitioner and
• Is identified by the beneficiary, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care

"Attending physicians" who meet this requirement and providers who are billing for Part B services unrelated to the patient’s terminal condition should bill with one or more of the following HCPCS modifiers, if appropriate:

GV — Attending physician not employed or paid under arrangement by the patient's hospice provider

HCPCS modifier GV must be submitted when a service meets the following conditions, regardless of the type of provider:

• The service was rendered to a patient enrolled in a hospice; 
• The service was provided by a physician or nonphysician practitioner identified as the patient's "attending physician" at the time of that patient's enrollment in the hospice program;
• The "attending physician" is not employed or paid under arrangement by the patient's hospice provider; and 
• Submit this modifier regardless of whether the services were related to the patient's terminal condition

HCPCS modifier GV should not be submitted when a service meets the following conditions:

• The service was provided by a physician employed by the hospice 
• The service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician

GW — Condition not related to the patient's terminal condition

• Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient's terminal condition
• All providers must submit this modifier when this condition applies

Q5 — Services furnished by a substitute physician under a reciprocal billing arrangement

• This modifier is used to indicate that a different physician has covered for the attending physician on the hospice record
• This modifier should be submitted in addition to the GV HCPCS modifier
• The services of the substituting physician are billed by the designated attending physician under the reciprocal or locum tenens billing instructions 
• See our Modifier Lookup article HCPCS MODIFIER Q5 for additional guidelines on using this modifier

Access CMS guidelines related to hospice:

• CMS Pub. 100-02, chapter 9 (PDF)
• CMS Pub. 100-04, chapter 11, section 40 (PDF)

Last Reviewed: 9/18/2024

The JW HCPCS modifier should only be applied to the amount of drug or biological that is discarded. For example, a single use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and five units discarded. The 95 unit dose is billed on one line, and the discarded 5 units is billed on another line with the JW HCPCS modifier. Both line items would be processed for payment. For more information, see our article HCPCS Modifier JW.

Resource: CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40 — Discarded Drugs and Biologicals (PDF).

Last Reviewed: 9/18/2024

The CPT® modifier 26 is used to indicate the professional component of the service being billed was "interpretation only," and it is most commonly submitted with diagnostic tests, including radiological procedures. When using the 26 modifier, you must enter it in the first modifier field on your claim.

For more information, please see the Physician Fee Schedule (PFS) Lookup Tool on the CMS website to determine if CPT® modifier 26 is applicable to a particular procedure code.

Complete definitions of supervision indicators are available in CMS Pub. 100-04, Chapter 23 (PDF) in the Addendum following Section 100.

Last Reviewed: 9/18/2024

Railroad Medicare adds a HCPCS modifier CC to a procedure code when the service is reviewed and downcoded or up-coded by our Medical Review or Appeals unit. When a reviewer determines the level of service billed is not supported by the documentation submitted, the procedure code is changed to, and payment is made for, the appropriate level of service.

Last Reviewed: 9/18/2024