Provider Manual

Modifier information

Last Updated on June 28, 2021

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 Topic #656	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

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Provider Manual

Modifier information