(Medicare Claims Processing Manual)

The following subsections provide information on the use of certain modifiers under the hospital OPPS. For information on additional modifiers not described below, refer to your MAC website(s) for guidance.  20.6.1 - Where to Report Modifiers on the Hospital Part B Claim  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  Modifiers are reported on the hardcopy Form CMS -1450 with the HCPCS code. See Chapter 25 of this manual for related instructions. For electronic submissions, see  the ASC X12 837 Institutional Claim implementation guide for instructions related to HCPCS modifiers when using the ASC X12 837 institutional claim format. Note there is space for four modifiers on the hardcopy and electronic forms.   HOPDs are reminded that the most specific modifier should be used first. That is, when modifiers E1 through E4, FA through F9, LC, LD, RC, and TA through T9 apply, they should be used before modifiers LT, RT, or 59.   20.6.2 - Use of Modifiers -50, -LT, and -RT (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  50: Bilateral Procedure   Modifier 50 is used to report bilateral procedures that are performed on both sides of the body at the same operative session. Do not report modifiers RT and LT when modifier 50 applies. Do not submit two line items to report a bilateral procedure using modifier 50. Report one line with modifier 50 using one unit of service.   Modifier 50 applies to any bilateral procedure performed on both sides at the same operative session. The bilateral modifier 50 is restricted to operative sessions only. Modifier 50 may not be used:   To report surgical procedures identified by their terminology as bilateral, or  To report surgical procedures identified by their terminology as unilateral or bilateral.   The unit entry to use when modifier 50 is reported is one unit.  20.6.3 - Modifiers -LT and - RT (Rev. 11937; Issued: 03 -31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  LT:  Left side (used to identify procedures performed on the left side of the body)  RT:  Right side (used to identify procedures performed on the right side of the body)   Modifiers LT and RT apply to codes that identify procedures that can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries.   These modifiers should be used whenever a procedure is performed on only one side. Hospitals should report the appropriate RT or LT modifier to identify which of the paired organs was operated upon. Do not report modifiers RT and LT when modifier 50 applies.   20.6.4 - Modifiers 73 and 74 (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  73: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia 74: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia   A. General   Modifiers 73 and 74 provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction applies t o both hospital outpatient departments (HOPDs) and to ambulatory surgical centers (ASCs).  Modifier 73 is used by the facility to indicate that a procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well -being of the patient after the patient had been prepared for the procedure (i ncluding procedural pre -medication when provided), and been taken to the room where the procedure was to be performed, but prior to administration of anesthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthes ia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.  Modifier 74 is used by the facility to indicate that a procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumsta nces or circumstances that threatened the well -being of the patient.   This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, and general anesthesia. This modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.  Coinciding with the addition of the modifiers 73 and 74, modifiers 52 and 53 were revised. Modifier 52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. Modifier 53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.   Note that the elective cancellation of a procedure should not be reported.   Modifiers 73 and 74 are only used to indicate discontinued procedures for which anesthesia is planned or provided.  B. Effect on Payment   Procedures that are discontinued after the patient has been prepared for the procedure and taken to the procedure room but before anesthesia is provided will be paid at 50 percent of the full OPPS payment amount. Modifier 73 is used for these procedures. A s of January 1, 2016, for device -intensive procedures that append modifier 73, we will reduce the APC payment amount for the discontinued device -intensive procedure by 100 percent of the device offset amount prior to applying the additional payment adjustments that apply when the procedure is discontinued as modified in the CY 2016 OPPS/ASC final rule that was published in the November 13, 2015 Federal Register (80 FR 70424-70426). Beginning January 1, 2017, device -intensive procedures are defined as those procedures requiring the insertion of an implantable device that also have a HCPCS -level device offset greater than 40 percent. From January 1, 2016, through December 31, 2016, device- intensive procedures were defined as those procedures that involve implantable devices that are assigned to a device- intensive APC (defined as those APCs with a device offset greater than 40 percent). Beginning January 1, 2019, device -intensive procedures are defined as procedures that involve the surgical implantation or insertion of an implantable device that is assigned a CPT or HCPCS code (including single -use de vices) and has a device offset amount that exceeds 30 percent of the procedures mean cost.   Procedures that are discontinued, partially reduced, or cancelled after the procedure has been initiated and/or the patient has received anesthesia will be paid at the full OPPS payment amount. Modifier 74 is used for these procedures.   Procedures for which anesthesia is not planned that are discontinued, partially reduced, or cancelled after the patient is prepared and taken to the room where the procedure is to be performed will be paid at 50 percent of the full OPPS payment amount. Modifier 52 is used for these procedures.    20.6.5 - Modifiers 76 and 77 (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  76: Repeat procedure or service by same physician or other qualified health care professional  77: Repeat procedure by another physician or other qualified health care professional   Two repeat procedure modifiers are applicable for hospital use:    Modifier 76 is used to indicate that the same physician or qualified health care professional repeated a procedure or service.    Modifier 77 is used to indicate that another physician or qualified health care professional repeated a procedure or service.   Since OPPS claims generally span only one calendar day, modifier 76 and 77 should be used to report procedures or services that are performed in a separate operative session on the same day or separate encounter on the same day.   If there is a question regarding whom the ordering physician/provider was and whether or not the same physician/provider ordered the second procedure, the code selected is based on whether or not the physician/provider performing the procedure is the same. The procedure must be the same procedure. It is listed once and then listed again with the appropriate modifier.   20.6.6 - Modifiers for Radiology Services  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  52: Reduced services  59: Distinct procedural service  76: Repeat procedure or service by same physician or other qualified health care professional  77: Repeat procedure by another physician or other qualified health care professional  Level II modifiers: use as applicable   Modifiers 52, 59, 76, and 77, and the Level II modifiers apply to radiology services.   When a radiology procedure is reduced, the correct reporting is to code to the extent of the procedure performed. If no HCPCS code exists for the service that has been completed, report the intended HCPCS code with modifier 52 appended.    20.6.7 - Modifier  CA (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  CA: Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission    In the CY 2003 OPPS final rule (67 FR 66799), we discussed the creation of the new HCPCS modifier CA to address situations where a procedure on the OPPS inpatient -only list must be performed to resuscitate or stabilize a patient (whose status is that of an  outpatient) with an emergent, life -threatening condition, and the patient dies before being admitted as an inpatient. HCPCS modifier CA is defined as a procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission. In section VI of Transmittal A 02129, issued on January 3, 2003, we instructed hospitals on the use of this modifier. Transmittal A -02-129 is available on the cms.gov website. For a complete description of the history of the policy and the development of the payment methodology for these services, refer to the CY 2004 OPPS final rule (68 FR 63467 through 63468), CY 2005 OPPS Final Rule (69 FR 65841), CY 2007 OPPS final rule (71 FR 68157 through 68158), and CY 2012 OPPS/ASC final rule (76 FR 74153 through 74154).   20.6.9 - Modifier  FB (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FB: Item provided without cost to provider, supplier, or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples)   From 2007 through 2013, HOPDs were required to report modifier FB when appropriate. As discussed in the CY 2007 OPPS final rule (71 FR 68076 through 68077), effective for services furnished on or after January 1, 2007, Medicare reduced the amount of payment for certain APCs when the hospital reported that it received a listed device without cost or where the hospital received a full credit for the cost of a replaced listed device. The reduction applied only when specific devices were replaced. To indicate t hat the hospital received the device without cost, modifier FB must have been reported.    In addition, OPPS hospitals were required to report modifier FB on the same line as the surgical or procedure code (not the HCPCS Level II device code) for a service that required a device for which neither the hospital, nor the beneficiary, was liable to the manufacturer. Similarly, hospitals were required to report modifier FB on the same line as the surgical or procedure code (not the device code) for a service that required a device when the manufacturer gave credit for a devi ce that was replaced with a more costly device.  Refer to section 61.3 of this manual for instructions regarding charges for items billed with the FB modifier.