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, 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.
|
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 |
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 |
| AQ | N | Does not affect payment | 80% of Medicare Fee Schedule | 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 |
| FY | N | 7% reduction | 7% reduction | Does not affect payment | 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 |