Modifier information
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, but is not an all-inclusive list. It 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.
For information on how to search the Forward Health Handbook or view the fee schedule, see steps outlined at the bottom of this page.
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 or 75% of contracted allowable, unless otherwise agreed to |
150% of fee schedule |
As allowed per ForwardHealth Fee Schedule |
150% of fee schedule or 75% of contracted allowable, unless otherwise agreed to |
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 |
80% of base fee |
Does not affect payment |
As allowed per ForwardHealth Fee Schedule See Topic #572 |
80% of base fee |
55 |
N |
20% 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 |
20% 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 |
AQ | N | Does not affect payment | Must be submitted for HPSA Bonus | Must be submitted for HPSA Bonus Topic #648 | Does not affect payment |
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 |
CS | Y - at the request of SHP | For COVID-19 testing-related services, waives member cost-share, if used appropriately | For COVID-19 testing-related services, waives member cost-share, if used appropriately | Does not affect payment | For COVID-19 testing-related services, waives member cost-share, if used appropriately |
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 |
To search the ForwardHealth Handbook for listed topic numbers: https://www.forwardhealth.wi.gov/WIPortal/Subsystem/KW/Display.aspx
- Click on "Online Handbook"
- Click “I Accept” and Submit Agreement
- Under User Type, select “Provider”
- Under Program, select “BadgerCare Plus & Medicaid”
- Click “Advanced Search”
- Enter appropriate topic number in search box
- Click “Search”
For access to the ForwardHealth fee schedule: https://www.forwardhealth.wi.gov/WIPortal/Subsystem/Publications/MaxFeeHome.aspx
- Click on “Interactive Mas Fee Schedule” on right-hand side
- Click “I Accept” and Submit Agreement
- Under Financial Payer, choose Medicaid
- Choose appropriate service area
- Enter procedure code
- Enter date of service
- Click search