Comprehensive and component code combinations performed on different eyelids are separately payable.
ET Emergency Services
FA Left Hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit F9 Right hand, fifth digit
Note: These modifiers can be used to indicate that rebundled services were performed on different digits. Separate payment will be allowed when column I & II services are performed on different digits.
G6 ESRD patient for whom less than six dialysis sessions have been provided in a month
G7 Pregnancy resulted from rape or incest or pregnancy certified by physicians as life threatening.
GA Beneficiary authorization
GC This service has been performed in part by a resident under the direction of a teaching physician.
GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception.
Note: GE, for this purpose, is for use on all services except ambulance. GG Performance and payment of screening mammogram and diagnostic mammogram on the same patient, same day.
GH Diagnostic mammogram converted from screening mammogram on the same day
GM Multiple patients on one ambulance trip
GN Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care
GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care
GP Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care
GR This service was performed in whole or in part by a resident in a department of Veterans Affairs Medical Center or clinic supervised in accordance with VA policy.
GT Via interactive audio and video telecommunication systems
GV Attending physician not employed or paid under arrangement by the patient’s hospice provider.
GW, GX, GY – Service not related to the hospice patients terminal condition. Service not covered by Medicare Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
The GY modifier should be used when billing for items or services that are statutorily excluded or do not meet the definition of any Medicare benefit. Example: routine physical exam. All services reported with the GY modifier will be denied by Medicare.
GZ Item or service expected to be denied as not reasonable and necessary
J1 Competitive Acquisition Program, no-pay submission for a prescription number
J2 Competitive Acquisition Program, restocking of emergency drugs after emergency administration
J3 Competitive Acquisition Program, (CAP) drug not available through CAP as written, reimburse under ASP Methodology
JA Administered Intravenously
JB Administered Subcutaneously
KC Replacement of special power wheelchair interface
KD Drug or biological infused through DME
KF Item designated by FDA as Class III device
KX Specific required documentation on file
KZ New coverage not implemented by managed care
M2 Medicare Secondary Payer for CAP
QA FDA investigational device exemption. FDA-approved investigational devices and/or services incident to the use of such devices should be billed using the appropriate HCPCS code and the QA modifier. When billing a service with the QA modifier, you are certifying FDA approval of a clinical trial for the device and that the device was approved at the time the service was rendered.
ET Emergency Services
FA Left Hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit F9 Right hand, fifth digit
Note: These modifiers can be used to indicate that rebundled services were performed on different digits. Separate payment will be allowed when column I & II services are performed on different digits.
G6 ESRD patient for whom less than six dialysis sessions have been provided in a month
G7 Pregnancy resulted from rape or incest or pregnancy certified by physicians as life threatening.
GA Beneficiary authorization
GC This service has been performed in part by a resident under the direction of a teaching physician.
GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception.
Note: GE, for this purpose, is for use on all services except ambulance. GG Performance and payment of screening mammogram and diagnostic mammogram on the same patient, same day.
GH Diagnostic mammogram converted from screening mammogram on the same day
GM Multiple patients on one ambulance trip
GN Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care
GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care
GP Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care
GR This service was performed in whole or in part by a resident in a department of Veterans Affairs Medical Center or clinic supervised in accordance with VA policy.
GT Via interactive audio and video telecommunication systems
GV Attending physician not employed or paid under arrangement by the patient’s hospice provider.
GW, GX, GY – Service not related to the hospice patients terminal condition. Service not covered by Medicare Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
The GY modifier should be used when billing for items or services that are statutorily excluded or do not meet the definition of any Medicare benefit. Example: routine physical exam. All services reported with the GY modifier will be denied by Medicare.
GZ Item or service expected to be denied as not reasonable and necessary
J1 Competitive Acquisition Program, no-pay submission for a prescription number
J2 Competitive Acquisition Program, restocking of emergency drugs after emergency administration
J3 Competitive Acquisition Program, (CAP) drug not available through CAP as written, reimburse under ASP Methodology
JA Administered Intravenously
JB Administered Subcutaneously
KC Replacement of special power wheelchair interface
KD Drug or biological infused through DME
KF Item designated by FDA as Class III device
KX Specific required documentation on file
KZ New coverage not implemented by managed care
M2 Medicare Secondary Payer for CAP
QA FDA investigational device exemption. FDA-approved investigational devices and/or services incident to the use of such devices should be billed using the appropriate HCPCS code and the QA modifier. When billing a service with the QA modifier, you are certifying FDA approval of a clinical trial for the device and that the device was approved at the time the service was rendered.
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