A. Policy
Aetna Better Health of Louisiana implements comprehensive and robust policies to ensure alignment with Louisiana Department of Health (LDH) and to warrant that regulatory standards are met. According to the AMA CPT Manual, the HCPCS Level II Manual and our policy, the anatomic specific modifiers, such as fingers, toes and coronary artery designate the area or part of the body on which the procedure is performed. It is correct coding to append modifiers to the greatest specificity at all times.
B. Overview
CPT and HCPCS Level II guidelines support the use of anatomic specific modifiers to develop policies which validate the area or part of the body on which a procedure is performed.
Procedure codes that do not specify right or left require an anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.
C. Definitions
Modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. Anatomical modifiers designate the area or part of the body on which the procedure is performed and assist in prompt, accurate adjudication of claims.
Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.
D. Reimbursement Guidelines
When submitting claims, always append an anatomical modifier, when applicable. Louisiana Department of Health Medicaid policy for both the commercial and Medicaid Advantage lines of business is that a claim is incomplete without an anatomical modifier, when applicable
E. Codes/Condition of Coverage
These codes are not all inclusive and for more please refer AMA CPT Manual, the HCPCS Level II Manual. These modifiers can be used with diagnostic, as well as therapeutic services.
Anatomical Modifiers:
Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.
LT, RT Modifiers LT and RT are only considered valid for procedure codes specific to body parts that exist only twice in the body, once on the left and once on the right (paired body parts). For example, eye procedures (e.g. cataract surgery) and knee procedures (e.g. total knee replacement).
Modifiers LT and RT should be used when a procedure was performed on only one side of the body, to identify which one of the paired organs was operated upon. LT and RT are not considered valid for toe procedures, excision of lesions, tendon/ligament injections (20550), or needle placements, etc. (Use finger and toe modifiers for finger and toe procedure codes; use eyelid modifiers for eyelid procedures.)
If the code description is for a structure that occurs multiple times on one side ofthe body (e.g. fingers, tendons, nerves, etc.) and is not specific enough for you to be able to mark on a body diagram where the left or right procedure is performed without looking at the medical record (e.g. place an “x” on the left shoulder for 73030-LT), then LT and RT are not valid modifiers. (Modifier -59 may be needed to indicate a separate lesion, separate nerve, separate tendon, etc. for nonpaired procedure codes.)
** To report an unplanned, unrelated procedure performed during postoperative period that is unrelated and not a result of the first surgery.
** To explain surgery/procedure.
Note
** Carrier may deny if modifier 79 is not included on the submitted claim.
** Claim should be submitted with a different diagnosis and documentation should support the medical necessity.
** The unrelated procedure starts a new global period.
** For repeat procedures on the same day, see modifier 76.
** Do not report modifier 79 with modifiers 58 or 78.
** Modifier 79 is an information modifier (not subject to payment reduction). Example
** January 22 – Patient is seen for an injury to the right index finger. The patient’s finger is amputated at the DIP joint.
** 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure.
** March 15 – Same patient has an amputation of the right leg at femur.
** 27590 – 79 Amputation, thigh, through femur, any level.
Blue Cross Requires use of Anatomical Modifiers
Effective February 1, 2019, Blue Cross and Blue Shield of Minnesota (Blue Cross) will change the Reimbursement Policy titled “General Coding-Modifier Policy”. Submission of anatomical modifiers to specify locations will be required when submitting claims.
Anatomical Modifiers
The following modifiers indicate a specific anatomic site. Because these modifiers affect edits and payment, effective February 1, 2019 Blue Cross requires the anatomical modifier(s) be submitted in the first modifier position, if applicable.
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
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
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LT Left side (used to identify procedures performed on the left side of the body)
RC Right coronary artery
RT Right side (used to identify procedures performed on the right side of the body)
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
Modifier Guidelines
procedures have been inappropriately billed by a surgical assistant. If guidelines are not met, the claim will suspend.
• Modifier 95 is used to designate when a service is a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.
• Modifier AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. Blue Cross and Blue Shield of North Carolina uses ClaimCheck® as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed by the physician assistant, nurse practitioner or nurse midwife.
• Modifier AX – item furnished in conjunction with dialysis services. J0604 and J0606 are drugs used for bone and mineral metabolism for the treatment of End Stage Renal Disease.
They are eligible for Transitional Drug Add-On Payment Adjustment when billed with AX modifier.
• HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate sitespecific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”).
• Modifier GQ designates services performed via asynchronous telecommunications system and will not be allowed.
• Modifier GT designates services performed via interactive audio and video telecommunication systems and will be allowed with codes specified in the Corporate Reimbursement Policy titled, “Telehealth.”
• Modifier MS – six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
• For Modifiers PA (surgical or other invasive procedure on wrong body part), PB (surgical or other invasive procedure on wrong patient), and PC (wrong surgery or other invasive procedure on patient), refer to Corporate Reimbursement Policy titled “Nonpayment for Serious Adverse Events”
• Modifier RA – Replacement of a DME item
• Modifier SZ – Effective 1/1/2017 in order to support Control/Home Plans’ compliance with the Federal requirement to separate visit limits for habilitative and rehabilitative services, Par/Host Plans may need to require that their providers are using the HCPCS modifier “SZ” when billing for habilitative services. (See policy titled “Rehabilitative Therapies”)
• Modifier RB – Replacement of a part of DME furnished as part of a repair
7 HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate site-specific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”). Notification given 11/28/17 for effective date of 1/27/18.
