CMS Modifier Percentage

The CMS Modifier Percentage tool lets you apply Medicare modifier reductions or reductions you specify to line items that have been repriced by another reimbursement tool, that is, a line item whose resources have been consumed. If the line item’s resources have not been consumed, it does not qualify for the reductions applied by the CMS Modifier Percentage tool.

You can also choose to virtually adjust Modifier 50 (Bilateral) procedures to ensure that these modifiers are priced correctly.

  • If you select the override percentage to check box, you can enter or edit the modifier percentage in the text box to the right.
  • Selecting the Virtually Adjust Modifier 50 check box automatically accounts for the various ways that bilateral procedures can be billed and ensures that these procedures are repriced correctly, regardless of the billing method on the claim.
  • Selecting the Apply bilateral proc rules to LT/RT codes check box applies bilateral procedures to codes with LT or RT modifiers.

The following table describes the fields on the CMS Modifier Percentage reimbursement tool.

Field

Description

50 - Bilateral procedures

Modifier value for bilateral procedures.

54 - Surgical procedure only

Modifier value for surgical procedures only.

55 - Follow-up care only

Modifier value for follow-up care only.

56 - Pre-op care only

Modifier value for pre-operative care only.

62 - Two surgeons

Modifier value for two surgeons.

66 - Team surgeons

Modifier value for a team of surgeons.

78 - Return to OR

Modifier value for a return trip to OR.

80 - Assistant surgeon

Modifier value for assistant surgeon.

81 - Minimum assistant surgeon

Modifier value for minimum assistant surgeon.

82 - Assistant surgeon without resident

Modifier value for assistant surgeon without resident.

AS - Assistant surgeon

Modifier value for assistant surgeon.

QK - 2, 3, or 4 concurrent anesthesia procedures

Modifier value for 2, 3, or 4 concurrent anesthesia procedures.

QY - CRNA directed by anesthesiologist

Modifier value for CRNA directed by anesthesiologist.

GY - Excluded from Medicare (patient liability)

Modifier value for claims excluded from Medicare.

GZ - Not medically necessary (not payable)

Modifier value for claims deemed not medically necessary.

GA - Waiver of liability on file (patient liability)

Modifier value to indicate a waiver of liability on file.

Apply bilateral proc rules to LT/RT codes

Allows you to apply bilateral procedures to codes with LT or RT modifiers.

override percentage to

Allows you to enter or edit the modifier percentage.

Virtually Adjust Modifier 50

Bilateral procedures (Modifier 50) can be billed in a variety of ways. Selecting this option automatically accounts for the various billing methods to ensure these procedures are repriced correctly.