Billing modifiers were created to provide additional information to the payer about the performed procedure(s) and help describe and/or qualify the services provided. There are common modifiers used by commercial payers and the Centers for Medicare and Medicaid Services (CMS), that indicate to the payer that the services provided have been altered in a way that is different than the ascribed definition of the billing code. For example, a modifier should be used when all of the tests in a bundled code were not performed or when only one ear was tested. Additionally, modifiers are also used to indicate how non-covered services are handled for a specific claim.

Coding requirements for current procedural terminology (CPT) modifiers can vary among payers, whereas some may not recognize certain modifiers. For tracking purposes and billing compliance, it is still necessary to supplement a billing code with a modifier when there is a change to the overall definition of the procedure or if procedures are considered non-covered services by CMS. The information in the tables provided is applicable to Medicare claims. Persons involved in submitting claims to Medicaid or payers other than CMS should gather state- or payer-specific information on the use of modifiers. The following tables and Q&As will provide guidance on when and why to use the different ascribed modifiers.

MEDICARE MODIFIERS

MODIFIER

WHEN TO USE MODIFIER

GA

Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case

Report when you issue a mandatory advance beneficiary notice of noncoverage (ABN) for a service as required and keep it on file. You do not need to submit a copy of the ABN, but you must have it available on request.

GX

Notice of Liability Issued, Voluntary Under Payer Policy

Report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier in combination with modifier GY.

GY

Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit

Report when Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. This modifier helps generate an auto-denial, which is helpful when the patient has a secondary insurance that may cover the service. This modifier may be used without administering an ABN. If an ABN is provided, then you could submit this modifier in combination with GX. 

GZ

Item or Service Expected to Be Denied as Not Reasonable and Necessary

Report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued. This should be a rare occurrence if referrals are reviewed before providing a service.

 

COMMON MODIFIERS

MODIFIER

WHEN TO USE THE MODIFIER

-22

Increased Procedural Services

Report when additional testing, resulting in increased time and complexity of procedure is required to perform the evaluation.

-26

Professional Component

(PC)

Report when only the interpretation and report are performed for a code that has both a professional component (PC) and a technical component (TC) (e.g., 92540-92542, 92544-92546, 92548, 92585, 92587, and 92588). For detailed guidance on PC/TC split.

Regarding hospital outpatient payment, a hospital bills for the TC and the audiologist bills for the PC (-26). The hospital may bill for the TC using a UB-92 form and the audiologist would bill for the PC alone using the CMS-1500 form. The key factor is whether or not the hospital provides the equipment, room space, hospital personnel, etc. If they do, then they bill for the TC. The modifier reflects whether it is the TC or PC (-26); reporting the code without a modifier indicates the global value (both TC and PC).

-33

Preventive Service

This modifier identifies preventive services such as newborn hearing screening or rescreening procedures. In some cases, these services are mandated by the Patient Protection and Affordable Care Act (ACA) and should not be subject to a patient cost share (i.e., co-pay, deductible, etc.).

As the use of modifiers varies widely between payers, it is recommended that you consult your payers to determine the recommended use for the -33 modifier for newborn hearing screening or rescreening procedures.

-52

Reduced Services

Report when only one ear is tested or if all components of a procedure were not performed (e.g., if one or more of the required test conditions for acoustic reflexes were not performed). 

This modifier cannot be used for time-based codes (e.g., 92626).

-59

Distinct Procedural Service

Report when two or more procedure codes are not normally reported together, but are appropriate under the circumstances (e.g. if not all four tests of 92540-Basic Vestibular Evaluation were performed, bill 1 to 3 of the following codes with modifier depending on procedures performed: 92546-59, 92548-59, 92587-59, 92588-59).

-TC

Technical Component (TC)

Report when only the technical portion of a procedure is performed (e.g., 92540-92542, 92544-92546, 92548, 92585, 92587, and 92588). For detailed guidance on PC/TC split.

Regarding hospital outpatient payment, a hospital bills for the TC and the audiologist bills for the PC (-26). The hospital may bill for the TC using a UB-92 form and the audiologist would bill for the PC alone using the CMS-1500 form. The key factor is whether or not the hospital provides the equipment, room space, hospital personnel, etc. If they do, then they bill for the TC. The modifier reflects whether it is the TC or PC (-26); reporting the code without a modifier indicates the global value (both TC and PC).

As a reminder, modifiers are not used on time-based codes such as 92626-Evaluation of Auditory Rehabilitation Status.

Q: How do I obtain a denial from Medicare for a claim when the secondary payer requires one?

A. The GY modifier should be appended to the CPT code to indicate an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. This modifier is used when seeking a denial for secondary payer purposes. If a voluntary Advance Beneficiary Notice of Noncoverage (ABN) is given to the patient for the non-covered service, the provider would also use the GX modifier along with the GY modifier. However, an ABN is not required in order to use the GY modifier and it may be submitted alone when a voluntary ABN is not provided.

Q. Where can I find information regarding the appropriate use of Medicaid modifiers?

A. Guidelines vary by state and providers should consult with each state's guidelines prior to billing.

The accurate use of billing codes and modifiers is not only an instrument for obtaining payment but also helps the profession of audiology on a national level. As trends are identified by CMS tracking, policies and guidelines are regularly revisited and/or updated to reflect changes in current practices and code usage. It is important to remember that outliers to these trends—providers who bill differently than their peers for the same services—may be audited because of a divergence from common coding practices. 

Accurate billing and coding practices keep providers within compliance, and they also provide useful information and statistical data for conducting research, evaluating health-care use, and developing practice guidelines. For more information on Medicare billing and appropriate modifier use, consult the following website addresses: 

Medicare Frequently Asked Questions

ABN Frequently Asked Questions

ABN Quick Reference Guide

Advanced Beneficiary Notice of Noncoverage Use: Mandatory or Voluntary?

Medicare Learning Network