22 – Increased Procedural Services: When the work required to provide a service is substantially is greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).
Note: This modifier should not be appended to an E/M service. It should only be reported with procedure codes that have a global period of 0, 10, or 90 days.
26 – Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. This modifier must be reported in the first modifier field.
32 – Mandated Services: Services related to mandated consultation and/or related services (e.g., third-party payer governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
52 – Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.
Modifier 52 is used for “unusual (reduced) circumstances.” It designates that the service performed was significantly less than usually required. In many instances, attachments, medical records, etc. are not required to be sent in if an explanation for the reduction is in the narrative field of the claim. For example, submit “one view only” in the narrative when only one view of a two view study is performed. Similarly “right side only” may be submitted when a procedure code that is bilateral by definition is not performed bilaterally. When additional information to support the use of the 52 modifier cannot be contained in the narrative of the claim, additional documentation may be submitted.
76 – Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier 76 to the repeated procedure or service.
Note: Do not report this modifier with ‘add-on’ codes denoted in CPT with a “+” sign. If a service defined as an ‘add-on’ code is repeated or provided more than once (based on description) on the same day by the same provider, report the ‘add-on’ code on one line with a multiplier in the unit field to indicate how many times that service was performed. For example, CPT 64636 (each additional facet joint) (billed in addition to primary/principle code 64635) is reported on one line as: 64636, units equal 3 (or the total number of additional facet joints (not bilateral) in addition to the initial/single facet joint billed under CPT code 64635). In this example, follow CPT instruction if provided bilaterally.
77 – Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service.
90 – Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier 90 to the usual procedure number.
For the Medicare program, this modifier is used by independent clinical laboratories when referring tests to a reference laboratory for analysis.
91 – Repeat Clinical Diagnostic Laboratory Test: In the same course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91.
Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
Modifier “-91” Definition – The “-91” modifier is used to indicate a repeat laboratory procedural service on the same day to obtain subsequent reportable test values. The physician may need to indicate that a lab procedure or service was distinct or separate from other lab services performed on the same day. This may indicate that a repeat clinical diagnostic laboratory test was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain subsequent reportable test values.
Rationale – Multiple laboratory services provided to a patient on one day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because these circumstances cannot be easily identified, a modifier “-91” was established to permit claims of such a nature to bypass correct coding edits. The addition of this modifier to a laboratory procedure code indicates a repeat test or procedure on the same day.
Instruction – The additional or repeat laboratory procedure(s) or service(s) must be identified by adding the modifier “-91”.
EXAMPLE 1: When cytopathology codes are billed, the appropriate CPT code to bill is that which describes, to the highest level of specificity, what services were rendered. Accordingly, for a given specimen, only one code from a family of progressive codes (subsequent codes include services described in the previous CPT code, e.g., 88104-88107, 88160-88162) is to be billed. If multiple services on different specimens are billed, the “-91” modifier should be used to indicate
that different levels of service were provided for different specimens.
This should be reflected in the cytopathologic reports.
92 – Alternative Laboratory Platform Testing: When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier.
UnitedHealthcare Community Plan Professional/Technical Splits
UnitedHealthcare Community Plan uses the Center for Medicare and Medicaid Services’ (CMS) PC/TC indicators as set forth in the “CMS Payment Policies” under the National Physician Fee Schedule Relative Value File to determine whether a CPT or HCPCS procedure code is eligible for separate professional and technical services reimbursement.
CPT or HCPCS codes assigned a CMS PC/TC Indicator 1 are comprised of a Professional Component and a Technical Component which together constitute the Global Service. The Professional Component (PC), (supervision and interpretation) is reported with modifier 26, and the Technical Component (TC) is reported with modifier TC.
The term “professional/technical split” is used to reference a Global Service assigned a PC/TC Indicator 1 that may be “split” into a Professional and Technical Component. CPT or HCPCS codes assigned a PC/TC Indicator 1 are listed in the National Physician Fee Schedule Relative Value File. Each Global Service is listed on a separate row followed immediately by separate rows listing the corresponding Technical Component, and Professional Component.
CPT or HCPCS codes with CMS PC/TC indicators 0, 2, 3, 4, 5, 7, 8, and 9 are not considered eligible for reimbursement when submitted with modifiers 26 and/or TC.
CPT or HCPCS codes with CMS PC/TC indicator 6 are not considered eligible for reimbursement when submitted with modifier TC.
CMS publishes this information in the “Physician Fee Schedule, PFS Relative Value Files” page, accessible through the following website:
Physician Fee Schedule Relative Value Files
UnitedHealthcare Community Plan’s percentage splits are developed on a national level from the CMS NonFacility Total Resource Based Relative Value Scale (RBRVS) based percentage splits. UnitedHealthcare Community Plan’s splits are updated quarterly and differ no more than 2.5% (for each CPT and HCPCS code) from the CMS Non-Facility Total RBRVS based percentage splits. The current splits are attached to this policy in the next section.
Services assigned a PC/TC Indicator 1 that CMS indicates may be carrier-priced, or those for which CMS does not develop RVUs are considered Gap Codes.
Gap Fill Codes: When data is available for Gap Codes, UnitedHealthcare Community Plan uses the relative values published in the first quarter update of the Optum The Essential RBRVS publication for the current calendar year.
2016A UnitedHealthcare Community Plan Professional Technical Component Policy Gap Fill Codes Gap Codes that are eligible for PC/TC per CMS but do not have RVUs established, or data available for gap fill, are included in the “Codes Subject to the CMS PC/TC Concept Without RVU Splits” list below and are allowed at 100% of the Allowable Amount for both the Professional Component and Technical Component.
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