Background Information Modifiers
Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code.
CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS). Like CPT codes, the use of modifiers requires explicit understanding of the purpose of each modifier. Modifiers provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:
• To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery
• To indicate that a procedure was performed bilaterally
• To report multiple procedures performed at the same session by the same provider
• To report only the professional component or only the technical component of a procedure or service
• To designate the specific part of the body that the procedure is performed on (e.g. T3 = Left foot, fourth digit)
• To indicate special ambulance circumstances
More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes.
Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational.
Modifiers are not intended to be used to report services that are “similar” or “closely related” to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service.
Anesthesia
Anesthesia is the administration of a drug or anesthetic agent by an anesthesiologist or CertifiedRegistered Nurse Anesthetist (CRNA) for medical or surgical purposes to relieve pain and/or induce partial or total loss of sensation and/or consciousness during a procedure. A variety of levels of anesthesia exist, ranging from local through general anesthesia. “As physicians, anesthesiologists are responsible for administering anesthesia to relieve pain and for managing vital life functions during surgery.” (ASA3 )
Supervised Anesthesia
At times a physician will provide medical direction and oversight for a qualified anesthetist (CRNA) or a resident/student performing anesthesia services. The physician may supervise a CRNA, resident, or student nurse anesthetist in a single anesthesia case or the physician may be medically directing 2, 3, or 4 concurrent procedures. Specific modifiers exist to designate the medical direction provided, the number of cases which are supervised, and whether or not the CRNA services were performed under the supervision or medical direction of a physician.
Codes, Terms, and Definitions
Modifier Definitions
Modifier AA Anesthesia services performed personally by anesthesiologist
Modifier AD Medical supervision by a physician: more than 4 concurrent anesthesia procedures
Modifier GC This service has been performed in part by a resident under the direction of a teaching physician
Modifier QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving
qualified individuals
Modifier QX Qualified nonphysician anesthetist with medical direction by a physician
Modifier QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist
Modifier QZ CRNA service: without medical direction by a physician
CRNA
Modifier Description Multiple
QX Anesthesia, CRNA medically directed 50%
QZ Anesthesia, CRNA not medically directed 100% Informational (no additional payment for informational modifiers) Modifier Description
QS Monitored anesthesia care (MAC) servcies (can be billed by CRNA or physician
G8 Monitored Anesthesia Care (MAC) for deep complex, complicated or markedly invasive surgical procedure
G9 Monitored Anesthesia Care (MAC) for patient who has history of severe cardiopulmonary condition
P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with server systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes
Medical direction and medical supervision modifiers:
– QY (Medical direction of one qualified non-physician anesthetist by an anesthesiologist)
– QK (Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals)
– AD (Medical supervision by a physician: more than 4 concurrent anesthesia procedures) Similarly, a CRNA should report the appropriate modifier.
when medical direction is provided by an anesthesiologist. When a claim is submitted by an anesthesiologist indicating that medical supervision or medical direction was provided, then a CRNA claim submitted with modifier QZ (CRNA service without medical direction by a physician) is incorrect will be denied. Multiple General Anesthesia Services on Same Day (Both Professional (1500) And Outpatient Facility- (1450)- When multiple anesthesia services are billed for the same day, the anesthesia provider should bill only the general anesthesia service for the procedure with the highest base value, plus the time for all anesthesia services combined. When a claim is received that contains multiple general anesthesia service codes (00100-01999), the highest submitted charge amount will be paid and the secondary anesthesia services will be denied.
Anesthesia Billing Guidelines
Anesthesia Services Providers are reminded of the anesthesia billing guidelines below. Gateway Health requires that all anesthesia services must be submitted with one of the following pricing modifiers in the first modifier position.
Required Anesthesia Modifiers
Modifier Description Reimbursement Percentage
AA Anesthesia Services performed personally by an anesthesiologist 100%
AD* Medical supervision by a physician for more than four concurrent anesthesia procedures 100%
QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals 50%
QX Qualified non-physician anesthetist with medical direction by a physician 50%
QY Medical direction of one qualified non-physician anesthetist by an anesthesiologist 50%
QZ CRNA service without medical direction by a physician 100%
Informational Modifiers
If reporting CPT modifier 23 or 47 or HCPCS modifier GC, G8, G9 or QS then no additional reimbursement is allowed above the usual fee for that service. Reimbursement
23 Unusual Anesthesia No additionalThis is considered an informational modifier only.
47 Anesthesia by Surgeon No additional – This is considered an informational modifier only.
GC This service has been performed in part by a resident under the direction of a teaching physician No additional – This is considered an informational modifier only.
G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
No additional –
This is considered an informational modifier only which should be billed along with a required anesthesia modifier and not be in the first modifier
G9 Monitored anesthesia care (MAC) for patient who has a history of severe cardiopulmonary condition No additional –
This is considered an informational modifier only which should be billed along with a required anesthesia modifier and not be in the first modifier position
QS Monitored anesthesiology care services (can be billed by a qualified nonphysician anesthetist or a physician)
No additional –
This is considered an informational modifier only which should be billed along with a required anesthesia modifier and not be in the first modifier position
XP Separate practitioner: a service that is distinct because it was performed by a different practitioner
XS Separate structure: a service that is distinct because it was performed on a separate organ/structure
Under certain circumstances, medical services and procedures may need to be further modified. Modifiers commonly used in anesthesia are :
22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number. A report may also be appropriate.
23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service.
47 Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia. Note: Modifier 47 would not be used as a modifier for the anesthesia procedures 00100–01999. The operating surgeon should report the surgical procedure 10021–69990 with modifier 47 appended when billing for anesthesia services.
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 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 cancelled 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 (see modifiers approved for ASC hospital outpatient use).
59 Distinct Procedural Service: Under certain circumstances, the medical provider 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.
AA Anesthesia Services performed personally by the anesthesiologist: Report modifier AA when the anesthesia services are personally performed by an anesthesiologist. Claims submitted with modifier AA are reimbursed at 100 percent.
AD Medical Supervision by a Physician; More Than Four Concurrent Anesthesia Procedures: Report modifier AD when the anesthesiologist supervises more than four concurrent anesthesia procedures. Claims submitted with modifier AD are reimbursed as described in the preceding section.
G8 Monitored Anesthesia Care (MAC) for Deep, Complex, Complicated or Markedly Invasive Surgical Procedures: Report modifier G8 when monitored anesthesia care is requied for deep, complex, complicated or markedly invasive surgical procedures.
G9 Monitored Anesthesia Care for Patient Who Has a History of Severe Cardiopulmonary Condition:
Report modifier
G9 when monitored anesthesia care is required for a patient who has a history of severe cardiopulmonary condition. NT No Time (State Specific Modifier): If the surgeon or attending physician administers a local or regional block for anesthesia during a procedure, the bill should so
indicate with the use of modifier NT for “no time.”
QK Medical Direction of Two, Three, or Four Concurrent Anesthesia Procedures Involving Qualified Individuals: Report modifier QK when the anesthesiologist supervises two, three, or four concurrent anesthesia procedures. Claims submitted with modifier QK are reimbursed at 50 percent.
QS Monitored Anesthesia Care Service: The QS modifier is for informational purposes.
QX CRNA Service with Medical Direction by a Physician: Regional or general anesthesia provided by the CRNA with medical direction by a physician may be reported by adding modifier QX. Claims submitted with modifier QX are reimbursed at 50 percent.
QY Medical Supervision by Physician of One CRNA: Report modifier QY when the anesthesiologist supervises one CRNA. Claims submitted with modifier QY are reimbursed at 50 percent.
QZ CRNA Service without Medical Direction by a Physician: Regional or general anesthesia provided by the CRNA without medical direction by a physician may be reported by adding modifier QZ. Claims submitted with modifier QZ are reimbursed at 100 percent.
Physical Status Modifiers
Six levels of physical status modifiers are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included to distinguish between various levels of complexity of the anesthesia service provided. A listing of physical status modifiers and the modifying units associated with each is provided in Subsection A, Payment Ground Rules for Anesthesia Services.
