Modifier Reference Guide

This document is a reference guide to provide information regarding modifier reimbursement practices for The Alliance contracted providers. The Alliance follows industry standards utilized by most payers, including Medicare and OPTUM’s Resource Based Relative Value System (RBRVS) to determine appropriateness of modifier use with CPT/HCPCS codes.

Below is a listing of the most commonly billed modifiers and The Alliance’s corresponding adjustment rate for standard contracts. (NOTE: This is not intended to be an all-inclusive list of CPT/HCPCS modifiers. Rates contained in your Participating Contract with The Alliance supersede rates listed below.)

Modifier Description Adjustment Rate
22 Unusual procedural service 125% of Contract Rate
50 Bilateral procedure 150% of Contract Rate
51 Multiple procedure 50% of Contract Rate
52 Reduced services 50% of Contract Rate
53 Discontinued procedure 50% of Contract Rate
54 Surgical procedure only 80% of Contract Rate
55 Postoperative management only 20% of Contract Rate
56 Preoperative management only 10% of Contract Rate
62 Two surgeons 62.5% of Contract Rate
63 Procedure performed on infants less than 4 kg. 125% of Contract Rate
73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia 50% of Contract Rate
78 Unplanned return to OR during post-op period 70% of Contract Rate
80 Assistant surgeon 20% of Contract Rate
81 Minimum assistant surgeon 10% of Contract Rate
82 Assistant surgeon 20% of Contract Rate
AA Administered by anesthesiologist 100% of Contract Rate
AD Medical supervision—more than 4 concurrent anesthesia procedures 100% of Contract Rate
AS Assistant at surgery: physician assistant, nurse practitioner or clinical nurse specialist 14% of Contract Rate for practitioner level
NU Purchased durable medical equipment Contract Rate
QK Medical direction of two, three or four concurrent anesthesia procedures 50% of Contract Rate
QX Administered by CRNA with medical direction 50% of Contract Rate
QY Anesthesiologist medically directs one CRNA 50% of Contract Rate
QZ Administered by CRNA without medical direction 100% of Contract Rate
P1 Healthy patient No additional units allowed
P2 Patient with mild systemic disease No additional units allowed
P3 Patient with severe systemic disease One additional unit
P4 Patient with severe systemic disease that is a constant threat to life Two additional units
P5 A morbid patient who is not expected to survive without the operation Three additional units
P6 A declared brain-dead patient whose organs are being removed for donor purposes No additional units allowed
RR Rental durable medical equipment Contract Rate

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