114.3 CMR 40.07

Current through Register 1527, August 2, 2024

Section 40.07 - Appendices

APPENDIX	DESCRIPTION
A	CPT and HCPCS Modifiers. Add the appropriate Level 1 CPT modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951. This table includes only common modifiers, any valid modifier may be used if it is appropriate to the situation.
B	Add-On Codes - Procedures that are commonly carried out in addition to the primary procedure performed and must never be reported as stand-alone codes. These codes are exempt from the multiple modifier '51' as are all codes that specify that they should be listed in addition to the main procedure.
C	Separate Procedures - Procedures that are stand alone codes. These codes are exempt from the multiple modifier '51'.
D	Drugs Administered Other Than Oral Method - List of drugs and biologicals that can be injected either subcutaneously, intramuscularly, or intravenously reimbursed at invoice cost.

APPENDIX A - Level I and Level II Common Modifiers This appendix lists the modifiers that are most commonly used in treating injured workers. The absence of a modifier from this appendix does not preclude its use in the appropriate situation.

(a)Anesthesia Modifiers.

1. Physical Status Modifiers. Physical status modifying units will be reimbursed if the patient is ranked in one of the following three categories. Physical status is included in CPT to distinguish various levels of complexity of the anesthesia service provided. Example: 00100-P3

Physical Status Modifiers	Description	Modifying Unit Value
P3	A patient with severe systemic disease.	1
P4	A patient with severe systemic disease that is a constant threat to life.	2
P5	A moribund patient who is not expected to survive without the operation.	3

2. CPT and HCPCS Modifiers for Anesthesia Services. Add the appropriate Level 1 CPT modifier or HCPCS Level II modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951.

Level 1 CPT Modifier 23 Unusual Anesthesia	Description Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service.
47 Anesthesia by Surgeon	Regional or general anesthesia provided by the surgeon may be reported by adding the modifier '-47' to the basic service. (This does not include local anesthesia.) Note: Modifier '-47' or 09947 would not be used as a modifier for the anesthesia procedures.
AA Anesthesia services performed personally by anesthesiologist	This modifier must be used in conjunction with the appropriate service code to denote medical direction of one or two concurrent anesthesia procedures involving residents in a teaching environment. Payment for the physician's medical direction service shall be made at 100% of the allowance for the service performed by the physician alone.
QK Medical Direction of Multiple Anesthesia Procedures	This modifier must be used in conjunction with the appropriate service code to denote medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. Payment for the physician's medical direction service shall be made at 50% of the allowance for the service performed by the physician alone.
QX CRNA Service	This modifier must be used to report services of a CRNA: with medical direction by a physician. This medical direction modifier is used when the physician medically directs two, three, or four concurrent procedures involving interns, residents, CRNAs and AAs. This allows 50% of the fee to be paid to the employer.
QY CRNA Service	This modifier must be used to report medical direction of one CRNA by an anesthesiologist. This allows 50% of the fee to be paid to the employer.
QZ CRNA Service	This modifier is used to report CRNA service: without medical direction by a physician. This allows 100% of the fee to be paid to the employer.

(b) CPT Modifiers for Clinical Laboratory Services. Add the appropriate Level 1 or Level II CPT modifier to the five digit code or identify the modifier by use of a separate code by adding 099 before the 2 digit number e.g. 09950, 09951.

Level 1 CPT Modifier	Description
-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.
-91 Repeat Clinical Diagnostic Laboratory Test	In the 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 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.

(c)HCPCS Modifiers for Durable Medical Equipment, Oxygen Delivery and Orthotic and Prosthetic Procedure Codes. Add the appropriate Level II HCPCS modifier to the five-digit code to identify the specific circumstance.

Level II CPT Modifier	Description
KH	DMEPOS item, initial claim, purchase or first month rental
KI	DMEPOS item, second or third month rental
KJ	DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to 15
KM	Replacement of facial prosthesis including new impression/moulage
KN	Replacement of facial prosthesis using previous master model
KR	Rental Item, billing for partial month
LL	Lease/Rental (use the 'LL' modifier when DME equipment rental is to be applied against the purchase price)
MS	Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
NR	New when rented (use the 'NR' modifier when DME which was new at the time of rental is subsequently purchased)
NU	New equipment
QE	Prescribed amount of oxygen is less than one liter per minute (LPM). This shall be reimbursed at 50% of the published rate of the appropriate service code.
QF	Prescribed amount of oxygen exceeds four liters per minute (LPM) and portable oxygen is prescribed. This shall be reimbursed at 150% of the published rate of the appropriate service code.
QG	Prescribed amount of oxygen is greater than four liters per minute (LPM). This shall be reimbursed at 150% of the published rate of the appropriate service code.
RP	Replacement and repair -RP may be used to indicate replacement of DME, orthotic and prosthetic devices which have been in use for sometime. The claim shows the code for the part, followed by the '-RP' modifier and the charge for the part
RR	Rental (use the 'RR' modifier when DME is to be rented)
UE	Used Durable Medical Equipment

(d) CPT and HCPCS Modifiers for Physicians' Services. Add the appropriate Level 1 CPT modifier or HCPCS Level II modifier to the five digit code.

Level 1 CPT Modifier	Description
21 Prolonged Evaluation and Management Services	When the face to face or floor/unit services(s) provided is prolonged or otherwise greater than that usually required for the highest level of evaluation and management service within a given category, it may be identified by adding modifier 21 to the evaluation and management code number. A report may also be appropriate
22 Unusual Procedural Service	When the work required to provide a service is substantially 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 (i.e., 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.
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service	It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately indentifiable /M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date, This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. For significant, separately identifiable See non-E/M services, see modifier 59
26 Professional Component (PC)	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 modifier -26 to the usual procedure number.
50 Bilateral Procedures	Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session, should be identified by adding modifier '50' to the appropriate five digit code. The addition of the modifier '50' to the second bilateral code allows 50% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the eligible provider for the second bilateral procedure.
51 Multiple Procedures	When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies(eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code. Note: This modifier should not be appended to designated "add-on" codes. The addition of the modifier 51 to the second and subsequent procedure code allows 50% of the allowable fee in 114.3 CMR 40.05 to be paid to the eligible provider.
52 Reduced Service	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 addition of the modifier 52 signifying the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. The fee will be based on individual consideration.
54 Surgical Care Only	When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier 54 to the usual procedure number. This allows 85% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the surgeon.
55 Postoperative Management Only	When one physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the physician that provided the postoperative management.
59 Distinct Procedure or Service	If a procedure or service not normally reported together was performed on the same day, the fee will be based on the full maximum fee of 100% of the payment group for the distinct procedure or service.
62: Pertains to Two Surgeons	Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. These circumstances may be identified by adding the modifier 62 to the procedure code used by each surgeon for reporting his services. The addition of the modifier 62 to the procedure codes allows 57.5% of the allowable fee contained in 114.3 CMR 40.05 to be paid to each surgeon. No separate fee may be charged for assisting surgical services in these cases; it is included in the total surgical fee and may be paid to both physicians based upon their agreement.
66: Pertains to Team Surgery	Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of modifier 66 to the basic procedure number used for reporting services. Payment of each physician should be as agreed upon by the team and the insurer.
76 Repeat Procedure by the 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 modifier 76 to the repeated procedure or service.
77 Repeat Procedure by Another Physician	The physician may need to indicate that a basic procedure or service performed by another physician has to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service.
78 Return to the Operating Room for a Related Procedure During the Postoperative Period	It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedure see modifier 76).
79 Unrelated Procedure or Service by the Same Physician during the Postoperative Period.	The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day see modifier 76).
80: Pertains to Assistant Surgeons	Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon.
81 Minimum Assistant Surgeon.	Minimum surgical assistant services are identified by adding the modifier 81 to the usual procedure number. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon.
82 Assistant Surgeon	(when qualified resident surgeon not available) The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code numbers. This allows 15% of the allowable fee contained in 114.3 CMR 40.05 to be paid to the assistant surgeon.
AS Assistant at Surgery	Physician assistant, nurse practitioner or clinical nurse specialist services for assistant at surgery.
SA Nurse Practitioner	Nurse practitioner rendering service in collaboration with a physician. This indicates reduced payment.
-SM Second Option	Second surgical opinion.
-SN Third Option	Third surgical opinion.

Appendix B - Add-On Codes Summary of CPT Add-On Codes for CPT 2008. Add on codes are identified in the CPT book with a "+".The CPT book is the final authority on the identification of add-on codes.

CODE
01953	15221	20937	26125
01968	15241	20938	26861
01969	15261	20985	26863
11001	15301	20986	27358
11008	15321	20987	27692
11101	15331	22103	31620
11201	15336	22116	31632
11732	15341	22208	31633
11922	15361	22216	31637
13102	15366	22226	32501
13122	15401	22328	33141
13133	15421	22522	33225
13153	15431	22525	33257
15003	15787	22527	33258
15005	15847	22534	33259
15101	16036	22585	33508
15111	17003	22614	33517
15116	17312	22632	33518
15121	17314	22840	33519
15131	17315	22841	33521
15136	19001	22842	33522
15151	19126	22843	33523
15152	19291	22844	33530
15156	19295	22845	33572
15157	19297	22846	33768
15171	20930	22847	33884
15176	20931	22848	33924
15201	20936	22851	33961
34806	61868	78480	99100
34808	62148	78496	99116
34813	62160	78730	99135
34826	63035	83901	99140
35306	63043	87187	99145
35390	63044	87904	99150
35400	63048	88155	99290
35500	63057	88185	99292
35572	63066	88311	99354
35600	63076	88312	99355
35681	63078	88313	99356
35682	63082	88314	99357
35683	63086	90466	99358
35685	63088	90468	99359
35686	63091	90472	99602
35697	63103	90474	99607
35700	63295	90761
36218	63308	90766
36248	64472	90767
36476	64476	90768
36479	64480	90770
37185	64484	90771
37186	64623	90775
37206	64627	90776
37208	64727	92547
37250	64778	92608
37251	64783	92627
38102	64787	92973
38746	64832	92974
38747	64837	92978
43635	64859	92979
44015	64872	92981
44121	64874	92984
44128	64876	92996
44139	64901	92998
44203	64902	93320
44213	66990	93321
44701	67225	93325
44955	67320	93571
47001	67331	93572
47550	67332	93609
48400	67334	93613
49326	67335	93621
49435	67340	93622
49568	69990	93623
49905	74301	93662
51797	75774	94645
56606	75946	95873
57267	75964	95874
58110	75968	95920
58611	75993	95962
59525	75996	95967
60512	76125	95973
61316	76802	95975
61517	76810	96411
61609	76812	96415
61610	76814	96417
61611	76937	96423
61612	77001	96570
61641	77051	96571
61642	77052	97546
61795	78020	97811
61864	78478	97814

APPENDIX C-- Codes Exempt from Modifier -51

Summary of CPT Separate Procedure Codes Exempt from Modifier 51 for CPT 2008. This list is not exhaustive. The CPT book identifies all codes exempt from modifier 51 and is the final authority on the matter.

CODE
17004	93539	93602	93631
20974	93540	93603	94610
20975	93544	93610	95900
31500	93545	93612	95903
36620	93555	93615	95904
44500	93556	93616	99143
61107	93600	93618	99144
93503

Appendix D: Drugs Administered Other Than Oral Method

CODE	J0476	J0770	J1270
J0120	J0480	J0780	J1300
J0128	J0500	J0795	J1320
J0129	J0515	J0800	J1325
J0130	J0520	J0835	J1325
J0132	J0530	J0850	J1327
J0133	J0540	J0878	J1330
J0150	J0550	J0881	J1335
J0152	J0560	J0882	J1364
J0170	J0570	J0885	J1380
J0180	J0580	J0886	J1390
J0190	J0583	J0894	J1410
J0200	J0585	J0895	J1430
J0205	J0587	J0900	J1435
J0207	J0592	J0945	J1436
J0210	J0594	J0970	J1438
J0215	J0595	J1000	J1440
J0220	J0600	J1020	J1441
J0256	J0610	J1030	J1450
J0270	J0620	J1040	J1451
J0275	J0630	J1051	J1452
J0278	J0636	J1055	J1455
J0280	J0637	J1056	J1457
J0282	J0640	J1060	J1457
J0285	J0670	J1070	J1460
J0287	J0690	J1080	J1470
J0288	J0692	J1094	J1480
J0289	J0694	J1100	J1490
J0290	J0696	J1110	J1500
J0295	J0697	J1120	J1510
J0300	J0698	J1160	J1520
J0330	J0702	J1162	J1530
J0348	J0704	J1165	J1540
J0350	J0706	J1170	J1550
J0360	J0710	J1180	J1560
J0364	J0713	J1190	J1561
J0365	J0715	J1200	J1562
J0380	J0720	J1205	J1565
J0390	J0725	J1212	J1566
J0395	J0735	J1230	J1568
J0400	J0740	J1240	J1569
J0456	J0743	J1245	J1570
J0460	J0744	J1250	J1571
J0470	J0745	J1260	J1572
J0475	J0760	J1265	J1573
J1580	J2270	J2805	J3487
J1590	J2271	J2810	J3488
J1595	J2275	J2820	J3490
J1600	J2278	J2850	J3520
J1610	J2280	J2910	J3530
J1620	J2300	J2916	J3535
J1626	J2310	J2920	J3570
J1630	J2315	J2930	J3590
J1631	J2320	J2940	J7030
J1640	J2321	J2941	J7040
J1642	J2322	J2950	J7042
J1644	J2325	J2993	J7050
J1645	J2353	J2995	J7060
J1650	J2354	J2997	J7070
J1652	J2355	J3000	J7100
J1655	J2357	J3010	J7110
J1670	J2360	J3030	J7120
J1700	J2370	J3070	J7130
J1710	J2400	J3100	J7187
J1720	J2405	J3105	J7189
J1730	J2410	J3110	J7190
J1740	J2425	J3120	J7191
J1742	J2430	J3130	J7192
J1743	J2440	J3140	J7193
J1745	J2460	J3150	J7194
J1751	J2469	J3230	J7195
J1752	J2501	J3240	J7197
J1756	J2503	J3243	J7198
J1785	J2504	J3246	J7199
J1790	J2505	J3250	J7300
J1800	J2510	J3260	J7302
J1810	J2513	J3265	J7303
J1815	J2515	J3280	J7304
J1817	J2540	J3285	J7306
J1825	J2543	J3301	J7307
J1830	J2545	J3302	J7308
J1835	J2550	J3303	J7310
J1840	J2560	J3305	J7311
J1850	J2590	J3310	J7321
J1885	J2597	J3315	J7322
J1890	J2650	J3320	J7323
J1931	J2670	J3350	J7324
J1940	J2675	J3355	J7330
J1945	J2680	J3360	J7340
J1950	J2690	J3364	J7341
J1955	J2700	J3365	J7342
J1956	J2710	J3370	J7343
J1960	J2720	J3395	J7344
J1980	J2724	J3396	J7346
J1990	J2725	J3400	J7347
J2001	J2730	J3410	J7348
J2010	J2760	J3411	J7349
J2020	J2765	J3415	J7500
J2060	J2770	J3420	J7501
J2150	J2778	J3430	J7502
J2170	J2780	J3465	J7504
J2175	J2783	J3470	J7505
J2180	J2788	J3472	J7506
J2185	J2790	J3473	J7507
J2210	J2791	J3475	J7509
J2248	J2792	J3480	J7510
J2250	J2795	J3485	J7511
J2260	J2800	J3486	J7513
J7515	J8520	J9212
J7516	J8521	J9213
J7517	J8530	J9214
J7518	J8540	J9215
J7520	J8560	J9216
J7525	J8565	J9217
J7599	J8597	J9218
J7602	J8600	J9219
J7603	J8610	J9225
J7604	J8650	J9226
J7605	J8700	J9230
J7607	J9000	J9245
J7608	J9001	J9250
J7609	J9010	J9260
J7610	J9015	J9261
J7615	J9017	J9263
J7620	J9020	J9264
J7622	J9025	J9265
J7624	J9027	J9266
J7626	J9031	J9268
J7627	J9035	J9270
J7629	J9040	J9280
J7631	J9041	J9290
J7632	J9045	J9291
J7633	J9050	J9293
J7634	J9055	J9300
J7635	J9060	J9303
J7636	J9062	J9305
J7637	J9065	J9310
J7638	J9070	J9320
J7639	J9080	J9340
J7640	J9090	J9350
J7641	J9091	J9355
J7642	J9092	J9357
J7643	J9093	J9360
J7644	J9094	J9370
J7645	J9095	J9375
J7647	J9096	J9380
J7648	J9097	J9390
J7649	J9098	J9395
J7650	J9100	J9600
J7658	J9110
J7659	J9120
J7660	J9130
J7667	J9140
J7668	J9150
J7669	J9151
J7670	J9160
J7674	J9165
J7676	J9170
J7680	J9175
J7681	J9178
J7682	J9181
J7683	J9182
J7684	J9185
J7685	J9190
J7699	J9200
J7799	J9201
J8498	J9202
J8499	J9206
J8501	J9208
J8510	J9209
J8515	J9211

114.3 CMR 40.07