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Provider Manual

Modifier information

Last Updated on August 28, 2018

When necessary, to adjudicate claims, Security Health Plan may request physician notes for claims submitted with certain modifiers. Modifiers may also impact reimbursement. The chart below includes common modifiers, indicates if physician notes are needed and if the modifier impacts reimbursement.

*The information below is a guideline. Please review your provider contract to determine how modifiers may affect payment. If there is conflict between this reference guide and your contract with Security Health Plan or applicable law, the terms of your contract or the applicable law will supersede this guide.

To search the ForwardHealth Handbook for listed topic numbers: https://www.forwardhealth.wi.gov/WIPortal/Subsystem/KW/Display.aspx

  1. Click on "Online Handbook"
  2. Click “I Accept” and Submit Agreement
  3. Under User Type, select “Provider”   
  4. Under Program, select “BadgerCare Plus & Medicaid”
  5. Click “Advanced Search”
  6. Enter appropriate topic number in search box
  7. Click “Search”

For access to the ForwardHealth fee schedule: https://www.forwardhealth.wi.gov/WIPortal/Subsystem/Publications/MaxFeeHome.aspx

  1. Click on “Interactive Max Fee Schedule” on right-hand side
  2. Click “I Accept” and Submit Agreement
  3. Under Financial Payer, choose Medicaid
  4. Choose appropriate service area
  5. Enter procedure code
  6. Enter date of service
  7. Click search 

Modifier

May require physician notes (Y/N)

Commercial

Medicare Advantage

Medicaid

FHC

22

Submit with notes for possible additional reimbursement

125% of fee schedule

Does not affect payment

As allowed for DME, vision, and hearing per ForwardHealth Fee Schedule

125% of fee schedule

24

Y

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

25

Y

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

26

N

% of global fee

As allowed per Medicare Fee Schedule

As allowed per ForwardHealth Fee Schedule

% of global fee

50

N

150% of fee schedule

150% of fee schedule

As allowed per ForwardHealth Fee Schedule

Topic #656

150% of fee schedule

51

N

50% of base fee

50% of base fee

50% of base fee

See Topic #656

50% of base fee

52

N

75% of Base Fee

50% of base fee

As allowed per ForwardHealth Fee Schedule

75% of Base Fee

53

Y for Medicare Advantage, DSNP/Ally, and MSA/Secure Saver

N for all other product lines

75% of Base Fee

50% of base fee

Does not affect payment

75% of Base Fee

54

N

% of base fee

Does not affect payment

As allowed per ForwardHealth Fee Schedule

See Topic #572

% of base fee

55

N

% of base fee

Reimburse a per diem per day to each provider who provided post-op care

Reimburse a per diem per day to each provider who provided post-op care

See Topic #572

% of base fee

56

N

% of base fee

Does not affect payment

Not separately reimbursable

Topic #572

% of base fee

59

Y

Does not affect payment

Does not affect payment

As allowed for DME per ForwardHealth Fee Schedule

Does not affect payment

62

Y

63% of base fee

62.5% of base fee

As allowed for DME per ForwardHealth Fee Schedule

Topic #656

63% of base fee

63

Y

125% of fee schedule

Does not affect payment

Does not affect payment

125% of fee schedule

66

Y

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

73

N

50% of Base Fee

50% of Base Fee

Does not affect payment

50% of Base Fee

76

N

Does not affect payment

Does not affect payment

As allowed for vision per ForwardHealth Fee Schedule

Does not affect payment

77

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

78

Y

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

79

Y

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

80 (must use the AS modifier for PA)

Y

20% of fee schedule

16% of fee schedule

20% of FowardHealth Fee Schedule

Topic #656 & 578

20% of fee schedule

81 (must use the AS modifier for PA)

Y

20% of fee schedule

16% of fee schedule

20% of FowardHealth Fee Schedule

Topic #656 & 578

20% of fee schedule

82 (must use the AS modifier for PA)

Y

20% of fee schedule

16% of fee schedule

20% of FowardHealth Fee Schedule

Topic #656 & 578

20% of fee schedule

90

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

AA

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

AD

N

Pays as quantity of 3

Does not affect payment

Does not affect payment

Pays as quantity of 3

AS

N

16% of physician base fee

16% of fee schedule

20% of FowardHealth Fee Schedule

Topic #656 & 578

16% of physician base fee

AT

N

Does not affect payment

Does not affect payment

Does not apply

Does not affect payment

AQ

N

Does not affect payment

80% of Medicare Fee Schedule

Must be submitted for HPSA Bonus

Topic #648

Does not affect payment

P1

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

P2

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

P3

N

Pay as a quantity of 1

Pay as a quantity of 1

Does not affect payment

Pay as a quantity of 1

P4

N

Pay as quantity of 2

Pay as a quantity of 2

Does not affect payment

Pay as a quantity of 2

P5

N

Pay as quantity of 3

Pay as quantity of 3

Does not affect payment

Pay as quantity of 3

P6

N

Not payable

Not payable

Does not affect payment

Not payable

Q6

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

QK

N

50% of base fee

50% of base fee

As allowed for Anesthesia per ForwardHealth Fee Schedule

50% of base fee

QS

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

QX

N

50% of base fee

50% of base fee

As allowed for Anesthesia per ForwardHealth Fee Schedule

50% of base fee

QY

N

50% of base fee

50% of base fee

As allowed for Anesthesia per ForwardHealth Fee Schedule

50% of base fee

QZ

N

Does not affect payment

Does not affect payment

As allowed for Anesthesia per ForwardHealth Fee Schedule

Does not affect payment

RA

N

Does not affect payment

Does not affect payment

As allowed for DME per ForwardHealth Fee Schedule

Does not affect payment

RB

N

Does not affect payment

Does not affect payment

Does not affect payment

Does not affect payment

RR

N

Total monthly rentals not to exceed purchase price

As allowed per Medicare fee schedule

As allowed for DME per ForwardHealth Fee Schedule

Total monthly rentals not to exceed purchase price

SG

N

Does not affect payment

Not used for Medicare ASC facility claims

As allowed per ForwardHealth Medical – Ambulatory Surgical Center Fee Schedule

Topic #1634

Does not affect payment

TC

N

% of global fee

As allowed per Medicare fee schedule

As allowed per ForwardHealth Fee Schedule

% of global fee