1) Modifiers provide information about services performed and circumstances that don't change the code definition. They indicate components, multiple procedures, sites of service and other details. 2) Harvard Pilgrim accepts up to two modifiers per claim line. Additional modifiers will not be rejected but only the primary two will impact reimbursement. 3) Several common modifiers are described that may impact reimbursement such as 22 for unusual services, 50 for bilateral procedures, and 59 for distinct services. Documentation may be required for consideration.

1. PAYMENT POLICIES
CPT and HCPCS Level II Modifiers1
For details on First Seniority Freedom, see the Product Portfolio section of this Provider Manual.
Definition
A Modifier provides the means by which the reporting physician/service can indicate that a service or procedure that has
been performed has a specific circumstance but not changed in its definition or code. The use of modifiers eliminates
the need for separate procedure listing that may describe the modifying circumstance. A modifier may be used to indi-
cate whether:
• A service or procedure has a professional component
• A service or procedure has a technical component
• A service or procedure was performed by more than one physician and/or in more than one location
• Only part of a service was performed
• A bilateral procedure was performed
• A service or procedure was provided more than once
• Unusual events occurred
• A service or procedure was performed on a specific site
• An add-on or additional service was performed
The presence or absence of one of the following modifiers may affect claims payment or result in a claim denial. For a
complete list of modifiers, refer to your CPT and HCPCS coding guideline manuals.
Multiple Modifiers
Harvard Pilgrim accepts up to two modifiers per line. Use of modifier will impact reimbursement when submitted as the
primary or secondary modifier. For claim lines submitted with more than two modifiers, only the primary and secondary
modifiers will be accepted. Harvard Pilgrim will not reject claims submitted with three or more modifiers.
CPT Modifiers
Modifier Description Reimbursement Impact
• For claims processed as of 01/01/2012 antepartum E&M vis-
its due to pregnancy complications that exceed the typical
care (14 visits) will be given individual consideration when
modifier is appended to the global obstetrical codes (CPT
22 Unusual procedural services
codes 59400, 59510, 59610 or 59618) and supported by the
medical documentation.
• For other services after appropriate use of modifier is vali-
dated, 120% of the fee schedule/allowable amount
23 Unusual anesthesia Modifier use will not impact reimbursement
After appropriate use of modifier is validated, 100% of the
Unrelated evaluation and management service by the fee schedule/allowable amount; E&M services billed with
24
same physician during a postoperative period modifier 24 when the diagnosis code is related to the surgi-
cal service will be denied
• Same day preventive & sick E&M: Lower valued E/M service
reimbursed at 50% of the fee schedule/allowable amount
• Effective 01/01/2011—Same day E&M and any service that
25 Significant, separately identifiable E&M service by the
has a global period indicator as designated by CMS of 0,
same physician on the same day of the procedure or
10, 90 or YYY. E&M reimbursed at 50% of the fee sched-
service
ule/allowable amount
• Other separately identifiable E&M service, modifier use
will not impact reimbursement
Modifier is used for procedures subject to 26 modifier as
26 Professional component
defined by CMS. Based on fee schedule/allowable amount
Multiple outpatient hospital E&M encounters on the
27
same date Modifier use will not impact reimbursement
32 Mandated services
(continued)
Harvard Pilgrim Health Care—Provider Manual H.61 October 2011

2. PAYMENT POLICIES
CPT and HCPCS Level II Modifiers (cont.)
Modifier Description Reimbursement Impact
No additional reimbursement is allowed for anesthesia by a
47 Anesthesia by surgeons surgeon, assistant surgeon, nursing staff or any other non-
anesthesiologist professional during a procedure
50 Bilateral procedure (see Bilateral Services Policy) 150% of the fee schedule/allowable
Primary procedure is reimbursed at 100% of the fee sched-
51 Multiple procedures ule/allowable, subsequent procedures reimbursed at 50% of
the fee schedule/allowable amount
Effective 01/01/2010—50% of the fee schedule/allowable
52 Reduced services
amount
53 Discontinued procedure Effective 04/01/2010—25% of the fee schedule/allowable
amount
54 Surgical care only 80% of the fee schedule/allowable amount
55 Postoperative management only
10% of the fee schedule/allowable amount
56 Preoperative management only
57 Decision for surgery
Staged or related procedure or service by the same phy- Modifier use will not impact reimbursement
58
sician during postoperative period
After appropriate use of modifier is validated, 100% of
the fee schedule/allowable amount; claims submitted with
operative/medical notes will be reviewed to determine
whether procedure code is distinct or independent from
59 Distinct procedural service other services:
- First time claim submissions can be submitted on paper
with operative notes for consideration
- Denied claims may be appealed with operative notes for
consideration
62 Two surgeons 62.5% of the fee schedule/allowable amount
63 Procedure performed on infants less than 4 kg. Modifier use will not impact reimbursement
Harvard Pilgrim will make a determination regarding reim-
66 Surgical team bursement after individual consideration and review of
operative notes
Discontinued outpatient procedure prior to
73 50% of the fee schedule/allowable amount
anesthesia administration
Discontinued outpatient procedure after
74 70% of the fee schedule/allowable amount
anesthesia administration
76 Repeat procedure by same physician
Modifier use will not impact reimbursement
77 Repeat procedure by another physician
Return to the operating room for a related procedure
78 80% of the fee schedule/allowable amount
during the postoperative period
Unrelated procedures or service by the same
79 Modifier use will not impact reimbursement
physician during the postoperative period
80 Assistant surgeon
81 Minimum assistant surgeon 16% of the fee schedule/allowable amount
Assistant surgeon (when qualified resident
82
surgeon not available)
90 Reference (outside) laboratory
Modifier use will not impact reimbursement
91 Repeat clinical diagnostic laboratory test
Physician assistant, nurse practitioner or clinical nurse
AS 16% of the fee schedule/allowable amount
specialist services for assistant at surgery
TC Technical component For procedures subject to TC modifier as defined by CMS
(continued)
Harvard Pilgrim Health Care—Provider Manual H.62 October 2011

3. PAYMENT POLICIES
CPT and HCPCS Level II Modifiers (cont.)
Common Modifiers for Anesthesia Claims
Modifier Description Reimbursement Impact
AA Anesthesia services performed personally by anesthesiologist 100% of Harvard Pilgrim anesthesia rate
AD Medical supervision by a physician; more than four concurrent 100% of Harvard Pilgrim anesthesia rate (three
anesthesia procedures base units)
QZ CRNA service: without medical direction by a physician 100% of Harvard Pilgrim anesthesia rate
QY Medical direction of one certified registered nurse Anesthetist
50% of Harvard Pilgrim anesthesia rate
by an anesthesiologist
Medical direction of two, three or four concurrent anesthesia
QK
procedures involving qualified individuals 50% of Harvard Pilgrim anesthesia rate
QX CRNA service: with medical direction by a physician
Monitored anesthesia care (MAC) provided by an Modifier use will not impact fee schedule
QS
anesthesiologist reimbursement
P1–P6 Anesthesia Physical Status Modifiers No reimbursement is allowed
HCPCS Modifiers
The following modifiers are helpful when multiple surgical procedures are performed on different anatomical sites dur-
ing the same operative session:
Modifier Modifier Description
Common Site-Specific Modifiers E1–E4 Eyelids
FA–F9 Finger
TA–T9 Toes
RT Right
LT Left
LD, RC Coronary vessels
Common DME Modifiers RT Right
LT Left
MS Maintenance and service fee
NU Purchased new equipment
RR Rental use
Common Early Intervention Modifiers AH Clinical psychologist
AJ Clinical social worker
GN Outpatient speech language
GO Outpatient occupational therapy
GP Outpatient physical therapy
HN Bachelor’s degree level
TD Registered nurse (RN)
TE Licensed practical nurse (LPN)
TJ Program group child
U1 Medicaid level of care 1 (defined by each state)
U2 Medicaid level of care 2 (defined by each state)
(continued)
Harvard Pilgrim Health Care—Provider Manual H.63 October 2011

4. PAYMENT POLICIES
CPT and HCPCS Level II Modifiers (cont.)
Modifier Modifier Description
Common Ambulance Modifiers GM Multiple patients on one trip
QM Ambulance service provided under arrangement by a provider of services
QN Ambulance service furnished directly by a provider of services
E Residential, domiciliary, custodial facility
Diagnostic or therapeutic site other than P or H, when these are used as
D
origin codes
G Hospital based dialysis facility (hospital or hospital related)
H Hospital
I Site of transfer (e.g., airport or helicopter pad)
J Non-hospital based dialysis facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
Destination code only—intermediate stop at physician’s office on the
X
way to the hospital
Physical and Occupational Therapy GP Services delivered under an outpatient physical therapy plan of care
Modifiers GO Services delivered under an outpatient occupational therapy plan of care
SL State-supplied vaccine
Other Miscellaneous Modifiers Services performed in part by a resident under the direction of a teach-
GC
ing physician. Services are not reimbursable to a resident
Related Policies
• Ambulance Payment Policy • Obstetrical/Maternity Care Payment Policy
• Bilateral Services and CPT Modifier 50 Payment Policy • Physical, Occupational, and Speech Therapy
• Durable Medical Equipment (DME) Payment Policy • Radiology Payment Policy
• Early Intervention Payment Policy • Surgery Payment Policy
• Evaluation and Management Payment Policy
PUBLICATION HISTORY
07/01/04 original documentation
07/01/05 policy update to modifiers 24 and 59
07/31/07 annual review
01/31/08 annual review; added multiple modifier information
07/31/08 policy update to bilateral procedure
01/31/09 annual coding update; removed mod 21
03/15/09 update to modifiers 78, 80, 81, 82, and AS
05/15/09 annual review: HCPC modifier tables updated, minor edit to modifier 59; added “Related Policies”
10/15/09 update to modifier 52
01/15/10 update to modifier 53, clarification of reimbursement impact for claims submitted with multiple modifiers
06/15/10 annual review; no changes
10/15/10 modifier 25 update–E&M’s with surgery/diagnostic procedure
11/15/10 modifier 25 minor edits for clarity
04/15/11 minor edits for clarity
06/15/11 annual review; added GO/GP modifiers
10/15/11 policy update to modifier 22, antepartum E&M visits due to complications will be given individual consideration; added Obstetrical/
Maternity Care to related policies
1This policy is in reference to HPHC, HPHC-NE, and HPHC Ins. Co. products for services performed by contracted providers. Payment is based on member
benefits and eligibility, medical necessity review, where applicable, and HPHC provider contractual agreement. Payment for covered services rendered by
contracted providers will be reimbursed at the lesser of charges or the contracted rate. (Does not apply to inpatient per diem, DRG, or case rates.) HPHC
reserves the right to amend a payment policy at its discretion. CPT and HCPCS codes are updated annually. Always use the most recent CPT and HCPCS
coding guidelines.
Harvard Pilgrim Health Care—Provider Manual H.64 October 2011