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Thursday 30 August 2012

Modifier Details

Modifiers for Medicare Billing

For Medicare purposes, modifiers are two-digit codes appended to procedure codes and/or HCPCS codes, to provide additional information about the billed procedure. In some cases, addition of a modifier may directly affect payment. Below is a list of modifiers including the modifier description and/or instructions and whether the modifier affects the Medicare payment.

Ambulance Claim Modifiers
Modifiers that are used on claims for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of X, represents an origin (source) code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code = origin; the second position alpha code = destination.
Origin and destination codes and their descriptions are listed below:
D
Diagnostic or therapeutic site other than "P" or "H" when these are used as origin codes
E
Residential, domiciliary, custodial facility (other than an 1819 facility)
G
Hospital based dialysis facility (hospital or hospital related)
H
Hospital
I
Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
J
Non-hospital based dialysis facility
N
Skilled nursing facility (SNF) (1819 facility)
P
Physician's office (includes HMO non-hospital facility, clinic, etc.)
R
Residence
S
Scene of accident or acute event
X
(Destination code only) Intermediate stop at physician's office in route to the hospital (includes HMO non-hospital facility, clinic, etc.)
GM
Multiple patients on one ambulance trip
QL
Patient pronounced dead after ambulance called
QM
Ambulance service provided under arrangement by a provider of services*
QN
Ambulance service furnished directly by a provider of services*
*The QM and QN modifiers are valid for Medicare; however, the services would be denied under Part B Medicare as a Part A Medicare expense.




Anesthesia Code Modifiers
AA
Anesthesia services personally performed by anesthesiologist - Distinct fee schedule amount. Affects payment.
AD
Medical supervision by a physician: More than 4 concurrent anesthesia procedures -. Distinct fee schedule amount. Affects payment.
G8
Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9
Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
QK
Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals - 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by a physician or non-supervised CRNA.
QS
Monitored anesthesia care- No effect on payment. For informational purposes only. Must be used in conjunction with a pricing anesthesia modifier.
QX
CRNA service with medical direction by physician- 1999 services limits the payment to 50% of the amount that would have been allowed if personally performed by physician or non-supervised CRNA.
QY
Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.
QZ
CRNA service without medical direction by a physician - No effect on payment. Payment is equal to the amount that would have been allowed if personally performed by a physician.
23
Unusual anesthesia - Used to report a procedure which usually requires either no anesthesia or local anesthesia; however, because of unusual circumstances must be done under general anesthesia. Coverage /payment will be determined on a "by-report" basis.
47
Anesthesia by surgeon - Used to report regional or general anesthesia provided by the surgeon (Not covered by Medicare).




Clinical Research Studies
Q0 (zero)
Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Q1
Routine clinical service provided in a clinical research study that is in an approved clinical research study



Coronary Angioplasty, Atherectomy and Stent Procedures (CPT codes 92980, 92981, 92982, 92984, 92996)
LC
Left circumflex coronary artery
LD
Left anterior descending coronary artery
RC
Right coronary artery




Diagnostic Procedures/Laboratory Modifiers
GG
Diagnostic Mammography - Performance and payment of a screening mammography and diagnostic mammography on same patient, same day. (Moved from other section/alpha order)
LT
Left Side - Used to identify procedures performed on the left side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
RT
Right Side - Used to identify procedures performed on the right side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
LR
Laboratory Round Trip - No effect on payment
QP
Panel test - Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes 80002-80019, G0058, G0059, and G0060. No effect on payment- but may assist with medical necessity determinations.
QW
CLIA Waived Test - Effective October 1, 1996, all new waived tests are being assigned a CPT code (in lieu of a temporary five-digit G- or Q-code). The CPT code should be billed with a modifier QW by entities holding a Certificate of Waiver.
TC
Technical component only - Use to indicate that the technical or professional component is reported separately (from the professional component) for the diagnostic procedure performed. The fee schedule contains different payment amounts for technical components. Affects payment.
UN
Portable X-ray Modifiers; two patients
UP
Portable X-ray Modifiers; three patients
UQ
Portable X-ray Modifiers; four patients
UR
Portable X-ray Modifiers; five patients
US
Portable X-ray Modifiers; six patients
26
Professional component only - Use to indicate that the physician component is reported separately (from the technical component) for the diagnostic procedure performed. The fee schedule contains different payment amounts for professional components. Affects payment.
90
Reference lab - Used to indicate a lab test sent to a referral (outside) lab, e.g., lab procedure performed by a party other than the treating or reporting laboratory. Note: Referral lab name, address and/or PIN must be included with the claim. No effect on payment.
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 the modifier -'91'. Note: This modifier may not be used when test 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 test, 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.




End Stage Renal Disease (ESRD) Modifiers
AX
Item furnished in conjunction with dialysis services.
CB
Services ordered by a dialysis facility physician as part of the ESRD beneficiary's dialysis benefit.
CD
AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable
CE
AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity
CF
AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable
EJ
Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab
EM
Emergency reserve supply (for ESRD benefit only) - No effect on payment.
G1
Most recent URR reading of less than 60
G2
Most recent URR reading of 60 to 64.9
G3
Most recent URR reading of 65 to 69.9
G4
Most recent URR reading of 70 to 74.9
G5
Most recent URR reading of 75 or greater
G6
ESRD patient for whom less than seven dialysis sessions have been provided in a month




Evaluation/Management Code Modifiers
AI
Principal Physician of Record. Used by the admitting or attending physician who oversees the patient's care, as distinct from other physicians who may be furnishing specialty care
24
Unrelated E/M service during a post op period - Use with E/M codes only to indicate that the E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. Modifier 24 applies to unrelated E/M services for either MAJOR or MINOR surgical procedure. Failure to use this modifier when appropriate may result in denial of the E/M service.
25
Significant, separately identifiable - Evaluation and Management service by the same physician on the same day as the procedure or other service. The physician may need to indicate that on the day a procedure or service 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. 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.
57
Decision for surgery - Use with E/M codes billed by the surgeon to indicate that the E/M service resulted in the decision for surgery (E/M visit was NOT usual preoperative care).For E/M visits prior to MAJOR surgery (90-day post op period) only. Failure to use this modifier when appropriate may result in denial of the E/M service.
Foot Care Modifiers
National modifiers were established to allow the class findings to be reported without writing a narrative description. The following modifiers should be used in conjunction with "covered routine" foot care procedures (e.g., 11055, 11056, 11057, 11719) to indicate the severity of the patient's systemic condition.
Q7
One CLASS A finding
Q8
Two CLASS B findings
Q9
One CLASS B and two CLASS C findings
Non-Physician Practitioner Modifier
AS
Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member. Reimburses at the Non Physician practitioner rate of 85% of the Medicare Physician Fee Schedule, then Assistant at surgery rate of 16% of the calculated non physician practitioner rate.
Occupational Therapist
GO
Services delivered under an outpatient occupational therapy plan of care.
Other Modifiers for Medicare Claims
AP
Determination of refractive state was not performed in the course of diagnostic ophthalmological examination. No effect on payment.
AQ
Physician providing a service in an unlisted health professional shortage area (HPSA). For dates of service on or after January 1, 2006.
AT
Acute treatment (chiropractic claims) - This modifier should be used when reporting CPT codes 98940, 98941, 98942 or 98943 for acute treatment. No effect on payment.
CC
Procedure code change- CARRIER USE ONLY - Used by carrier to indicate that the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed. No effect on payment. Payment determination will be based on the "new" code used by the carrier.
CR
Catastrophe/disaster related. It is required when an item or service is impacted by an emergency or disaster and Medicare payment for such item or service is conditioned on the presence of a “formal waiver”.
EA
Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy
EB
Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy
EC
Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
EJ
Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab.
ET
Emergency treatment - Use to designate a dental procedure performed in an emergency situation. No effect on payment.
FB
Item provided without cost to provider, supplier or practitioner, or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples)
GA
Waiver of liability statement on file - Use to indicate that the physician's office has a signed advance notice retained in the patient's medical record. The notice is for services that may be denied by Medicare. No effect on payment; however, potential liability determinations are based in part on the use of modifier. Updated description effective April 1, 2010: Waiver of Liability Statement Issued, as Required by Payer Policy. This modifier should be used to report when a required ABN was issued for a service.
GJ
Opted Out physician or practitioner - Use to indicate services performed in an emergency or urgent service.
GS
Dosage of EPO or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.
GV
Attending physician not employed or paid under agreement by the patient's hospice provider.
GW
Service not related to the hospice patient's terminal condition.
GX
Notice of Liability Issued, Voluntary Under Payer Policy. This modifier should be used to report when a voluntary ABN was issued for a service.
GY
Use to indicate when an item or service statutorily excluded or does not meet the definition of any Medicare benefit.
GZ
Use to indicate when an item or service expected to be denied as not reasonable and necessary. Used when no Advanced Beneficiary Notice (ABN) signed by the beneficiary.)
G7
Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening
JA
Administered intravenously
JB
Administered subcutaneously
KB
Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim
KD
Drug or biological infused through DME.
KX
Updated description effective April 1, 2010: Requirements specified in the medical policy have been met. May be used when a therapy exception is appropriate or should be billed with any procedure code(s) that are gender specific for the affected beneficiaries.
KM
Replacement of facial prosthesis - including new impression/moulage
KN
Replacement of facial prosthesis - Using previous master model
KZ
New Coverage not implemented by managed care
M2
Medicare Secondary Payer
QC
Single channel monitoring - No effect on payment.
QD
Recording and storage in solid state memory by a digital recorder - No effect on payment.
QJ
Services/items provided to a prisoner or patient in state or local custody, however the State or Local government, as applicable, meets the requirements in 42 CFR 411.4(B)
QT
Recording and storage on tape by an analog tape recorder - No effect on payment.
Q3
Liver Kidney Donor Surgery and Related Services - No effect on payment.
Q4
Service for ordering/referring physician qualifies as a service exemption - No effect on payment.
Q5
Service furnished by a substitute physician under a reciprocal billing arrangement - No effect on payment.
Q6
Service furnished by a locum tenens physician - No effect on payment.
SK
Member of high risk population (Use only with codes for immunization)
32
Mandated services - Services related to mandated consultations and/or related services (e.g., PRO, third party payer, governmental, legislative or regulatory requirement) may be identified by adding the modifier '-32' to the base procedure.
59
Distinct Procedural Service - Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier '-59' is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier '-59' only if no more descriptive modifier is available, and the use of modifier '-59' best explains the circumstances, should modifier '-59' be used.

Correct Coding Initiative (CCI) Modifier:
Modifier 59 does not replace modifiers 24, 25, 50, 51, 78 ,79, RT and LT
Modifier 59 is not used on Evaluation and Management CPT codes.
99
Multiple modifiers- Use only when more than four modifiers are needed to describe a service. The additional modifiers should be included with the claim (item 19 on paper submissions, or appropriate message or freeform area on electronic submissions).No effect on payment; however, the individual modifiers listed will apply, including any potential effect they may on payment.




Out-patient Hospital/Ambulatory Surgical Center (ASC)
73
Discontinued out-patient hospital or ambulatory surgical center (ASC) procedure prior to the administration of anesthesia - Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general). Under these circumstances, the intended service that is prepared for but canceled can be reported by its usual procedure number and the addition of the modifier -73 or by use of the separate five digit modifier code 09973. Note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier -53.
SG
Ambulatory Surgical Center (ASC) modifier - This modifier identifies those services performed in the ASC facility that will generate a facility fee allowance. This modifier is NOT used by the performing physician/surgeon. Beginning January 1, 2008, ASCs no longer are required to include the SG modifier on facility claims to Medicare.
74
Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia - Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier -74 or by use of the separate five-digit modifier code 09974.Note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported for physician reporting of a discontinued procedure, see modifier -53.



Physical Therapist
GP
Services delivered under an outpatient physical therapy plan of care.
Physician Quality Reporting Initiative (PQRI) Modifiers
Performance Measure Exclusion Modifiers indicate that an action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the medical record. Performance measure exclusion modifiers fall into one of three categories:
1P
Performance Measure Exclusion Modifier due to Medical Reasons:
Includes: Not Indicated (absence of organ/limb, already received/performed, other); Contraindicated (patient allergic history, potential adverse drug interaction, other)
2P
Performance Measure Exclusion Modifier due to Patient Reasons:
Includes: patient declined; economic, social, or religious reasons; other patient reasons
3P
Performance Measure Exclusion Modifier due to System Reasons includes:
Resources to perform the services not available; insurance coverage/payor-related limitations; other reasons attributable to health care delivery system.

Performance Measure Reporting Modifier:
Facilitates reporting a case when the patient is eligible but an action described in a measure is not performed and the reason is not specified or documented.

8P
Performance Measure Reporting Modifier- Action not performed, reason not otherwise specified




Positron Emission Tomography (PET)
PI
Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.
PS
Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy.




Speech-Language Pathologist
GN
Services delivered under an outpatient speech language pathology plan of care.




Surgical Procedure Expanded Modifiers: Hands-Feet-Eyelids
The following modifiers should be used in conjunction with procedures of the hands, feet and eyelids. The modifiers will not affect the payment amount; however, failure to use these modifiers when appropriate could result in claim delay or denial.
E1
Upper left, eyelid
E3
Upper right, eyelid
E2
Lower left, eyelid
E4
Lower right, eyelid



FA
Left hand, thumb
F5
Right hand, thumb
F1
Left hand, second digit
F6
Right hand, second digit
F2
Left hand, third digit
F7
Right hand, third digit
F3
Left hand, fourth digit
F8
Right hand, fourth digit
F4
Left hand, fifth digit
F9
Right hand, fifth digit



TA 
Left foot, great toe
T5 
Right foot, great toe
T1 
Left foot, second digit
T6 
Right foot, second digit
T2 
Left foot, third digit
T7 
Right foot, third digit
T3 
Left foot, fourth digit
T8 
Right foot, fourth digit
T4 
Left foot, fifth digit
T9 
Right foot, fifth digit



Surgical Procedure Modifiers
LT
Left Side - Used to identify procedures performed on the left side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
PA
Surgical or other invasive procedure on wrong body part
PB
Surgical or other invasive procedure on wrong patient
PC
Wrong surgery or other invasive procedure on patient
RT
Right Side - Used to identify procedures performed on the right side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
22
Unusual procedural services - Used on surgery codes. An operative note should be submitted with the claim. May result in increased payment. DOCUMENTATION must be submitted.
50
Bilateral procedure - Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier -50 to the appropriate five digit code.
51
Multiple procedures - When multiple procedures, other than evaluation and management services, are performed on the same day or 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 adding modifier '-51' to the additional procedure or service code(s). MODIFIER 51 IS NOT REQUIRED FOR BILLING PURPOSES: The carrier will assign the multiple procedure modifier if appropriate based on the services billed.

PAYMENT RULES: We approve 100% of the fee schedule amount for the highest valued procedure, 50% for the 2nd-5th procedures and "by report" for subsequent procedures. Payment determined on a “by report” basis for these codes should never be lower than 50 percent of the full payment amount.

EXCEPTIONS: Multiple endoscopies: Special rules for multiple endoscopic procedures apply if the procedure is billed with another endoscopy in the same family. See CMS Internet Only Manual, Pub. 100-04, Chapter 12, Section 40.6 for endoscopy rules.
52
Reduced services - 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 the addition of the modifier -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital out-patient reporting of a previously scheduled procedure or service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of a patient prior to or after administration of anesthesia, see modifiers -73 and -74 (these modifiers are approved for ASC hospital out-patient use).
53
Discontinued procedure - Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier '-53' to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers -73 and -74 (modifiers approved for ASC and hospital out-patient use).
54
Surgical care only- Use with surgical codes when only the surgical service was performed. Payment will be limited to the amount allotted to the preoperative and intraoperative services only.
55
Postoperative care only - Use with surgical codes only to indicate that only the postoperative care was performed (another physician performed the surgery). Payment will be limited to the amount allotted for postoperative services only.
58
Staged or related procedure or service during the postoperative period- This modifier should be used to permit payment for a surgical procedure during the postoperative period of another surgical procedure when (1) the subsequent procedure was planned prospectively at the time of the original procedure, (2) a less extensive procedure fails and a more extensive procedure is required or (3) a therapeutic surgical procedure follows a diagnostic procedure e.g., a mastectomy follows a breast biopsy. Failure to use modifier when appropriate may result in denial of the subsequent surgery.
62
Two surgeons - When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single distinct procedure code. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedures) are performed during the same surgical session, separate codes may be reported without the modifier -62 added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s), with modifier -80 or modifier -81 added, as appropriate.
66
Surgical team - The modifier should be used by each participating surgeon to report his services. When team surgery is medically necessary, the carrier will determine the appropriate allowances(s) "by report."
76
Repeat procedure by same physician - The physician may need 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 had to be repeated. This situation may be reported by adding modifier -77 to the repeated procedure or service.
78
Return to OR for related surgery during postop period - Use on surgical codes only to indicate that another procedure was performed during the postoperative period of the initial procedure, was related to the first, and required the use of the operating room. Payment is limited to the amount allotted for intraoperative services only. Failure to use this modifier when appropriate may result in denial of the subsequent surgery.
79
Unrelated surgery during postop period - Use on surgical codes only to indicate that the performance of a procedure during the postoperative period of another surgery was unrelated to the original procedure. Failure to use this modifier when appropriate may result in denial of the subsequent surgery.
80
Assistant surgeon - Reimburses the assistant surgeon at 16% of the Medicare Physician Fee Schedule Data Base allowance for the surgical procedure.




Teaching Physician
GC
This service has been performed in part by a resident under the direction of a teaching physician.
GE
This service has been performed by a resident without the presence of a teaching physician under the primary care exception.




Teleconsultations
GQ
Via asynchronous telecommunications system
GT
Via interactive audio and video telecommunication systems



Medicare Denial Codes.

PR 1 Deductible Amount
PR 2 Coinsurance Amount
PR 3 Co-payment Amount
OA 4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
OA 5 The procedure code/bill type is inconsistent with the place of service.
OA 6 The procedure/revenue code is inconsistent with the patient's age.
OA 7 The procedure/revenue code is inconsistent with the patient's gender.
OA 8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
OA 9 The diagnosis is inconsistent with the patient's age.
OA 10 The diagnosis is inconsistent with the patient's gender.
OA 11 The diagnosis is inconsistent with the procedure.
OA 12 The diagnosis is inconsistent with the provider type.
OA 13 The date of death precedes the date of service.
OA 14 The date of birth follows the date of service.
CO 15 Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider.
OA 16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI 17 Payment adjusted because requested information was not provided or was Insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
OA 18 Duplicate claim/service.
OA 19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
OA 20 Claim denied because this injury/illness is covered by the liability carrier.
OA 21 Claim denied because this injury/illness is the liability of the no-fault carrier.
CO 22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
PI 23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments
CO 24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
PR 25 Payment denied. Your Stop loss deductible has not been met.
PR 26 Expenses incurred prior to coverage.
PR 27 Expenses incurred after coverage terminated.
CO 29 The time limit for filing has expired.
PR 31 Claim denied as patient cannot be identified as our insured.
PR 32 Our records indicate that this dependent is not an eligible dependent as defined.
PR 33 Claim denied. Insured has no dependent coverage.
PR 34 Claim denied. Insured has no coverage for newborns.
PR 35 Lifetime benefit maximum has been reached.
CO 38 Services not provided or authorized by designated (network/primary care) providers.
CO 39 Services denied at the time authorization/pre-certification was requested.
OA 40 Charges do not meet qualifications for emergent/urgent care.
OA 44 Prompt-pay discount.
CO 45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
CO 49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
CO 50 These are non-covered services because this is not deemed a `medical necessity' by the payer.
CO 51 These are non-covered services because this is a pre-existing condition
OA 53 Services by an immediate relative or a member of the same household are not covered.
CO 54 Multiple physicians/assistants are not covered in this case .
CO 55 Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer.
CO 56 Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer.
CO 58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
OA 59 Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)
CO 60 Charges for outpatient services with this proximity to inpatient services are not covered.
OA 61 Charges adjusted as penalty for failure to obtain second surgical opinion.
CO 66 Blood Deductible.
CO 69 Day outlier amount.
CO 70 Cost outlier - Adjustment to compensate for additional costs.
OA 74 Indirect Medical Education Adjustment.
OA 75 Direct Medical Education Adjustment.
CO 76 Disproportionate Share Adjustment.
CO 78 Non-Covered days/Room charge adjustment.
PR 85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)
OA 87 Transfer amount.
CO 89 Professional fees removed from charges.
OA 90 Ingredient cost adjustment.
CO 91 Dispensing fee adjustment.
CO 94 Processed in Excess of charges.
OA 95 Benefits adjusted. Plan procedures not followed.
CO 96 Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PI 97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated
OA 100 Payment made to patient/insured/responsible party.
CO 101 Predetermination: anticipated payment upon completion of services or claim adjudication.
CO 102 Major Medical Adjustment.
CO 103 Provider promotional discount (e.g., Senior citizen discount).
OA 104 Managed care withholding.
OA 105 Tax withholding.
OA 106 Patient payment option/election not in effect.
CO 107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim.
PI 108 Payment adjusted because rent/purchase guidelines were not met.
OA 109 Claim not covered by this payer/contractor. You must send the claim to the correct
payer/contractor.
CO 110 Billing date predates service date.
CO 111 Not covered unless the provider accepts assignment.
PI 112 Payment adjusted as not furnished directly to the patient and/or not documented.
CO 114 Procedure/product not approved by the Food and Drug Administration.
PI 115 Payment adjusted as procedure postponed or canceled. This change effective 1/1/2008: Payment adjusted as procedure postponed, canceled, or delayed.
OA 116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
CO 117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
OA 118 Charges reduced for ESRD network support.
CO 119 Benefit maximum for this time period or occurrence has been reached.
OA 121 Indemnification adjustment.
OA 122 Psychiatric reduction.
CO 125 Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
PR 126 Deductible -- Major Medical
PR 127 Coinsurance -- Major Medical
CO 128 Newborn's services are covered in the mother's Allowance.
CR 129 Payment denied - Prior processing information appears incorrect.
OA 130 Claim submission fee.
OA 131 Claim specific negotiated discount.
OA 132 Prearranged demonstration project adjustment.
OA 133 The disposition of this claim/service is pending further review.
OA 134 Technical fees removed from charges.
CO 135 Claim denied. Interim bills cannot be processed.
OA 136 Claim adjusted based on failure to follow prior payer’s coverage rules. (Use Group Code OA).
OA 137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
CO 138 Claim/service denied. Appeal procedures not followed or time limits not met.
CO 139 Contracted funding agreement - Subscriber is employed by the provider of services.
PR 140 Patient/Insured health identification number and name do not match.
OA 141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
CR 142 Claim adjusted by the monthly Medicaid patient liability amount.
OA 143 Portion of payment deferred.
CR 144 Incentive adjustment, e.g. preferred product/service.
PI 145 Premium payment withholding
CO 146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
OA 147 Provider contracted/negotiated rate expired or not on file.
OA 148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.
PR 149 Lifetime benefit maximum has been reached for this service/benefit category.
PI 150 Payment adjusted because the payer deems the information submitted does not support this level of service.
PI 151 Payment adjusted because the payer deems the information submitted does not support this many services.
PI 152 Payment adjusted because the payer deems the information submitted does not support this length of service.
PI 153 Payment adjusted because the payer deems the information submitted does not support this dosage.
PI 154 Payment adjusted because the payer deems the information submitted does not support this day's supply.
OA 155 This claim is denied because the patient refused the service/procedure.
OA 156 Flexible spending account payments
CO 157 Payment denied/reduced because service/procedure was provided as a result of an act of war.
CO 158 Payment denied/reduced because the service/procedure was provided outside of the United States.
CO 159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.
CO 160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.
OA 161 Provider performance bonus
CO 162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
CR 163 Claim/Service adjusted because the attachment referenced on the claim was not received.
CR 164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.
CO 165 Payment denied /reduced for absence of, or exceeded referral
PR 166 These services were submitted after this payers responsibility for processing claims under this plan ended.
CO 167 This (these) diagnosis(es) is (are) not covered.
PR 168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan
PI 169 Payment adjusted because an alternate benefit has been provided
CO 170 Payment is denied when performed/billed by this type of provider.
CO 171 Payment is denied when performed/billed by this type of provider in this type of facility.
CO 172 Payment is adjusted when performed/billed by a provider of this specialty
CR 173 Payment adjusted because this service was not prescribed by a physician
CO 174 Payment denied because this service was not prescribed prior to delivery
CO 175 Payment denied because the prescription is incomplete
CO 176 Payment denied because the prescription is not current
PR 177 Payment denied because the patient has not met the required eligibility requirements
CR 178 Payment adjusted because the patient has not met the required spend down requirements.
CR 179 Payment adjusted because the patient has not met the required waiting requirements
CR 180 Payment adjusted because the patient has not met the required residency requirements
CR 181 Payment adjusted because this procedure code was invalid on the date of service
CR 182 Payment adjusted because the procedure modifier was invalid on the date of service
CO 183 The referring provider is not eligible to refer the service billed.
CO 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
CO 185 The rendering provider is not eligible to perform the service billed.
OA 186 Payment adjusted since the level of care changed
OA 187 Health Savings account payments
CO 188 This product/procedure is only covered when used according to FDA recommendations.
OA 189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
CO 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
CO 191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers’ compensation carrier.
OA 192 Non standard adjustment code from paper remittance advice.
CO 193 Original payment decision is being maintained. This claim was processed properly the first time.
PI 194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician
PI 195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service
PI 197 Payment adjusted for absence of precertification/authorization. This change effective 1/1/2008: Payment adjusted for absence of precertification/authorization/notification.
PI 198 Payment Adjusted for exceeding precertification/ authorization.
OA 199 Revenue code and Procedure code do not match.
PR 200 Expenses incurred during lapse in coverage
PR 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement. (Use group code PR).
PI 202 Payment adjusted due to non-covered personal comfort or convenience services.
PI 203 Payment adjusted for discontinued or reduced service.
PR 204 This service/equipment/drug is not covered under the patient’s current benefit plan
CO 205 Pharmacy discount card processing fee
OA 206 NPI denial - missing
OA 208 NPI denial - not matched
OA 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)
PI 210 Payment adjusted because pre-certification/authorization not received in a timely fashion
CO 211 National Drug Codes (NDC) not eligible for rebate, are not covered.
PI A0 Patient refund amount.
OA A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
CO A4 Medicare Claim PPS Capital Day Outlier Amount.
CO A5 Medicare Claim PPS Capital Cost Outlier Amount.
OA A6 Prior hospitalization or 30 day transfer requirement not met.
CO A7 Presumptive Payment Adjustment
OA A8 Claim denied; ungroupable DRG
PR B1 Non-covered visits.
CO B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
OA B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
OA B12 Services not documented in patients' medical records.
OA B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
CO B14 Payment denied because only one visit or consultation per physician per day is covered.
OA B15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
CO B16 Payment adjusted because `New Patient' qualifications were not met.
OA B18 Payment adjusted because this procedure code and modifier were invalid on the date of service
OA B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
OA B22 This payment is adjusted based on the diagnosis.
CO B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
CO B4 Late filing penalty.
CO B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
CO B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
CR B8 Claim/service not covered/reduced because alternative services were available, and should have been utilized.
PR B9 Services not covered because the patient is enrolled in a Hospice.
PI W1 Workers Compensation State Fee Schedule Adjustment

Monday 20 August 2012

Timely Filling Limit

Timely Filling Limit:

1) Aetna : 120 days.
2) Amerigroup : 180 days.
3) Bcbs : 1yr.
4) Cigna : 180 days.
5) Humana : 15 months.
6) Greatwest : 1yr.
7) Medicare : 1 yr
8) Medicaid : 95 Days.
9) RR Medicare : 1yr.
10) UHC : 90 days.
11) Universal Healthcare: Depends upon the provider’s contract.
12) Polk Healthcare (Community Healthplan): 180 days.
13) Medicare Complete: 180 days.
14) Ever care : 180 days.
15) Quality Health Plan : 180 days.
16) Health Net : 120 days
17) foundation : 1 yr
18) Tricare : 1yr
19) Pacificare : 90 days
20) Abrazo : 180 days
21) Arizona BCBS : 365 days
22) Arizona Physicians IPA: 120 days
23) Harrington : 365 days
24) Mercy Care :180 days
25) Pacificare : 90 days
26) Phoenix Health Plan :180 days
27) Secure Horizons :90 days

US Insurance Companies

U.S. insurance companies

Annuity

Main article: Life annuity

Health insurance (major medical insurance)

Medicare

Supplemental insurance

Supplemental health insurance

Travel insurance

Main article: Travel insurance

Workers' compensation

Main article: Workers' compensation
  • Zenith Insurance Company



    Traditional Medicaid
    You get traditional Medicaid if you are not in the PCCM, STAR, or STAR+PLUS plans.
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    Primary Care Case Management (PCCM)

    Texas Medicaid and Healthcare Partnership (TMHP)

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    STAR
    Aetna Medicaid

    AMERIGROUP Community Care

    Community First Health Plans

    Community Health Choice

    Cook Children’s Health Plan

    Driscoll Children’s Health Plan

    El Paso First Premier

    FirstCare Health Plans

    Molina Healthcare of Texas

    Parkland Healthfirst

    Superior HealthPlan

    Texas Children’s Health Plan

    Unicare Health Plans

    UnitedHealthcare
    --------------------------------------------------------------------------------------
    STAR+PLUS


    AMERIGROUP Community Care

    Evercare

    Molina Healthcare of Texas

    Superior HealthPlan

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    Children’s Health Insurance Program Health Plans

    Children in the Children’s Health Insurance Program (CHIP) get their health and medical services through a health plan in their area. Some CHIP health plans also offer services to mothers who are pregnant. This is called CHIP perinatal coverage.
    You can find the CHIP health plans in your area by using the CHIP Health Plan Search tool.
    CHIP Health Plans
    Aetna Medicaid


    AMERIGROUP Community Care

    CHIP Member Handbooks:

    Community First Health Plans

    Community Health Choice

    Cook’s Children’s Health Plan

    Delta Dental

    Driscoll Children’s Health Plan

    El Paso First Premier


    FirstCare Health Plans


    Mercy Health Plans

    CHIP Perinatal Coverage Handbooks:

    Molina Healthcare of Texas

    Parkland Healthfirst


    Seton Healthplan

    Texas Children’s Health Plan
     
    Unicare Health Plans

    United Healthcare Texas