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 (For CPT Codes 1XXXX – 6XXXX) |
| 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 |