| Short Descr | Bls-emergency | Coverage | Carrier Priced | Pricing Indicator(s) | 52 – Reasonable charge | MPI | A – Not applicable, as HCPCS priced under one methodology | BETOS | O1A – Ambulance | TOS Code(s) | D – Ambulance | Added Date | 1/1/2001 | Status Code | Statutory Exclusion (from MPFS, may be paid under other methodologies) | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 9 - Not Applicable | Multiple Procedures (51) | 9 - Concept does not apply. | Bilateral Surgery (50) | 9 - Concept does not apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 9 - Concept does not apply. | Co-Surgeons (62) | 9 - Concept does not apply. | Team Surgery (66) | 9 - Concept does not apply. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Service Paid under Fee Schedule or Payment System other than OPPS | MUE | 2 | MUE | Not applicable/unspecified. | OTS Orthotic | No | CCS Clinical Classification | 239 - Transportation - patient, provider, equipment |
| SH | Second concurrently administered infusion therapy | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | HH | Integrated mental health/substance abuse program | GW | Service not related to the hospice patient's terminal condition | QL | Patient pronounced dead after ambulance called | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | HI | Integrated mental health and intellectual disability/developmental disabilities program | HN | Bachelors degree level | QN | Ambulance service furnished directly by a provider of services | RR | Rental (use the 'rr' modifier when dme is to be rented) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GM | Multiple patients on one ambulance trip | HR | Family/couple with client present | RI | Ramus intermedius coronary artery | SS | Home infusion services provided in the infusion suite of the iv therapy provider | CR | Catastrophe/disaster related | GH | Diagnostic mammogram converted from screening mammogram on same day | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | HE | Mental health program | 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. | U1 | Medicaid level of care 1, as defined by each state | 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 individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | EC | Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | ED | Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle | EE | Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle | EP | Service provided as part of medicaid early periodic screening diagnosis and treatment (epsdt) program | ER | Items and services furnished by a provider-based, off-campus emergency department | ET | Emergency services | EX | Expatriate beneficiary | GA | Waiver of liability statement issued as required by payer policy, individual case | GE | This service has been performed by a resident without the presence of a teaching physician under the primary care exception | GG | Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day | GL | Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn) | GN | Services delivered under an outpatient speech language pathology plan of care | GP | Services delivered under an outpatient physical therapy plan of care | GU | Waiver of liability statement issued as required by payer policy, routine notice | GX | Notice of liability issued, voluntary under payer policy | GZ | Item or service expected to be denied as not reasonable and necessary | HC | Adult program, geriatric | HD | Pregnant/parenting women's program | HG | Opioid addiction treatment program | HJ | Employee assistance program | HP | Doctoral level | HS | Family/couple without client present | HW | Funded by state mental health agency | HX | Funded by county/local agency | HY | Funded by juvenile justice agency | JE | Administered via dialysate | KX | Requirements specified in the medical policy have been met | LL | Lease/rental (use the 'll' modifier when dme equipment rental is to be applied against the purchase price) | MH | Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider | N1 | Group 1 oxygen coverage criteria met | NR | New when rented (use the 'nr' modifier when dme which was new at the time of rental is subsequently purchased) | NU | New equipment | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | PI | Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing | PN | Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital | PS | Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy | QG | Prescribed amount of stationary oxygen while at rest is greater than 4 liters per minute (lpm) | QH | Oxygen conserving device is being used with an oxygen delivery system | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | QM | Ambulance service provided under arrangement by a provider of services | Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional | RC | Right coronary artery | RD | Drug provided to beneficiary, but not administered "incident-to" | RE | Furnished in full compliance with fda-mandated risk evaluation and mitigation strategy (rems) | SC | Medically necessary service or supply | SD | Services provided by registered nurse with specialized, highly technical home infusion training | SE | State and/or federally-funded programs/services | SG | Ambulatory surgical center (asc) facility service | SJ | Third or more concurrently administered infusion therapy | SN | Third surgical opinion | SU | Procedure performed in physician's office (to denote use of facility and equipment) | SW | Services provided by a certified diabetic educator | SY | Persons who are in close contact with member of high-risk population (use only with codes for immunization) | TN | Rural/outside providers' customary service area | U2 | Medicaid level of care 2, as defined by each state | U3 | Medicaid level of care 3, as defined by each state | U8 | Medicaid level of care 8, as defined by each state | UA | Medicaid level of care 10, as defined by each state | UD | Medicaid level of care 13, as defined by each state | UJ | Services provided at night | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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Action
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Notes
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| 2001-01-01 | Added | Code added 1/1/2001 |