CurrentEmblemHealthPolicy RPC20210015

Modifier Reference Policy (Commercial and Medicaid)

Defines how specific CPT/HCPCS modifiers affect reimbursement for EmblemHealth Commercial and Medicaid products and provides guidance on when modifiers apply; intended for providers and billing staff submitting claims to EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyModifier Reference Policy (Commercial and Medicaid)

Policy CodePolicy RPC20210015

Change TypeNo material change

Effective DateSep 1, 2021

Next Review Date

Key ActionFollow coding/billing guidelines and apply modifiers per CPT/HCPCS and EmblemHealth guidance to avoid claim denials or recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~80+ modifiersmodifiers listed or referenced in tables

Examples: +20%, +50%, -50%, 0%common reimbursement impacts shown

0-3Anesthesia unit values

1/01/2022 & 1/01/2023new/effective dates noted

E1-E4, FA...RCsite-specific modifiers listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

multiplerevision history entries

Billing and Reimbursement Criteria

Billing rules and reimbursement stance

Provider must follow coding/billing guidelines and apply modifiers per CPT/HCPCS and EmblemHealth guidance. Noncompliance may result in denials or recoupment.

Provider must follow coding/billing guidelines and apply modifiers per CPT/HCPCS and EmblemHealth guidance; use CPT and HCPCS coding manuals and follow applicable industry coding edits (CPT, CMS/NCCI/MUE).

Append modifiers only where CPT/HCPCS guidance permits and as described in EmblemHealth modifier tables; some modifiers are limited to certain code ranges or claim types (professional vs facility).

Reimbursement adjustments indicated in the modifier tables and referenced reimbursement policies will be applied during claims adjudication; failure to follow appropriate coding/billing guidelines may result in claim denial or recoupment.

Refer to EmblemHealth reimbursement policies and provider resources (website) for additional guidance and for resolution of conflicts between coding sources; EmblemHealth uses industry-standard claims editing software and will apply edits it determines appropriate.

Site-specific modifier reimbursement stance

Stance on site-specific modifiers and reimbursement

Site-specific modifiers listed do not affect provider reimbursement.

Site-specific modifiers are anatomical/side indicators that identify where a service was performed; examples include E1-E4 (eyelid), FA/F1-F9 (fingers), TA/T1-T9 (toes), LT/RT (left/right), and coronary artery modifiers LC/LD/RC.

Certain site-specific modifiers are applicable only to specified CPT code ranges as indicated in the modifier reference (for example: E1-E4: 10021-68899; FA/ F1-F9 and TA/T1-T9: 10021-64999; LT/RT: 10021-69979; LC/RC: 92978-92984, 92995-92996).

Modifier and Code Guidance

Selected procedural modifiers (partial list)Modifier

22	Unusual Procedural Service
24	Unrelated E/M Service by the Same Physician During a Postoperative Period
25	Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day
26	Professional Component
50	Bilateral Procedure
51	Multiple Procedures
52	Reduced Services
53	Discontinued Procedure

Surgical/site/team modifiers (partial list)Modifier

54	Surgical Care Only
55	Postoperative Management Only
56	Preoperative Management Only
57	Decision for Surgery
59	Distinct Procedural Services
62	Two Surgeons
63	Procedure Performed on Infants less than 4 kg
66	Surgical Team
73	Discontinued Outpatient Procedure Prior to the Administration of Anesthesia
74	Discontinued Outpatient Procedure After Administration of Anesthesia

Miscellaneous/new modifiers and imaging/drug modifiersModifier

93	Synchronous Telemedicine Audio-Only
FX	X-ray on film
FY	X-ray using computed radiography/cassette-based imaging
JW	Drug amount discarded
JZ	Zero drug wasted or discarded
XE	Separate encounter
XP	Separate practitioner
XS	Separate structure
XU	Unusual non-overlapping service
CT	CT services using equipment not meeting NEMA XR-29

1–10 of 11

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Anesthesia modifiers and physical statusModifier

P1-P6	Anesthesia physical status modifiers with unit values
AA	Anesthesia services performed personally by anesthesiologist
AD	Medical supervision >4 concurrent procedures
QK	Medical direction of 2-4 concurrent anesthesia procedures
QX	CRNA service with medical direction
QY	Medical direction of one qualified non-physician anesthetist
QZ	CRNA service without physician direction

Site-specific modifier applicable CPT rangesCPT

10021-68899	CPT range where eyelid modifiers E1-E4 may apply
10021-64999	CPT range where finger modifiers FA, F1-F9 and toe modifiers TA, T1-T9 may apply
92978-92984, 92995-92996	CPT range where coronary artery modifiers LC and RC may apply
10021-69979	CPT range where side modifiers LT and RT may apply

inv-08: Typical reimbursement adjustments

Modifier 22Unusual Procedural Service — additional 20% of the allowable fee (pays 120% of fee).

Modifier 63Procedure performed on infants less than 4 kg — additional 20% of the allowable fee (pays 120% of fee).

Modifier 50Bilateral Procedure — additional 50% of the allowable fee (pays 150% of fee).

Modifier 52Reduced Services — reduced the allowable fee by 50% (pays 50% of fee).

Modifier 53Discontinued Procedure — reduced the allowable fee by 50% (pays 50% of fee).

Billing Actions and Risks for Providers

Denial Risk

Follow coding/billing guidance — risk of denial or recoupment

Follow applicable coding and billing guidelines (CPT/HCPCS and EmblemHealth guidance) when appending modifiers and submitting claims; failure to follow appropriate coding/billing guidance may result in claim denial and/or recoupment of payment.

Billing Rule

Site-specific modifiers do not change reimbursement

Site-specific modifiers (E1–E4, FA/F1–F9, TA/T1–T9, LT/RT, LC/LD/RC) are informational and do not affect provider reimbursement; they indicate the CPT code ranges where each modifier may apply.

E1–E4 (eyelid): CPT 10021–68899
FA, F1–F9 (fingers) and TA, T1–T9 (toes): CPT 10021–64999

Modifier Definitions and Notes

inv-12: Modifier — definition/term entry

DefinitionModifier — a CPT/HCPCS two‑digit suffix appended to a procedure or service code to indicate that the service or procedure has been altered in some way but not changed in its definition. Providers must follow CPT/HCPCS guidance and EmblemHealth modifier instructions when appending modifiers; improper use may result in denial or recoupment.

ApplicationAppend modifiers only where CPT/HCPCS guidance permits and per modifier tables; some modifiers are limited to certain code ranges or claim types (professional vs facility).

Adjudication impactReimbursement adjustments indicated in the tables will be applied per policy (examples: modifier 22 +20%; modifier 50 pays 150%; some modifiers pay 0%).

inv-13: Anesthesia Physical Status Modifiers

P1Normal healthy patient — Unit value = 0.

Policy Summary

PayerEmblemHealth

PolicyModifier Reference Policy (Commercial and Medicaid)

Policy CodePolicy RPC20210015

Change TypeNo material change

Effective DateSep 1, 2021

Next Review Date

Key ActionFollow coding/billing guidelines and apply modifiers per CPT/HCPCS and EmblemHealth guidance to avoid claim denials or recoupment.

SourceLink

On This Page

inv-09: Imaging reductions effective dates

FX/FY (radiography)Reduce the allowable fee by 10% effective 1/01/2023 (pays 90%).

CT (non‑NEMA XR‑29 equipment)Reduces the allowable by 15% (pays 85%).

SU (procedure in physician's office to denote facility & equipment)Reduced the allowable fee by 100% (pays 0%).

LT/RT (left/right): CPT 10021–69979

LC/RC (coronary arteries): CPT 92978–92984, 92995–92996

Patient with mild systemic disease — Unit value = 0.

P3Patient with severe systemic disease — Unit value = 1 (15 min).

P4Patient with severe systemic disease that is a constant threat to life — Unit value = 2 (30 min).

P5Moribund patient not expected to survive without the operation — Unit value = 3 (45 min).

P6Declared brain‑dead patient whose organs are being removed for donor purposes — Unit value = 0.

inv-14: Informational Only Modifiers

Modifiers (examples)23, 47, GC, G8, G9, QS — informational only; no additional reimbursement is allowed above the usual fee when reported.

23Unusual Anesthesia (informational only).

47Anesthesia by Surgeon (informational only).

GCService performed in part by a resident under teaching physician direction (informational only).

inv-15: Ambulance/Site-Specific Modifiers

General stanceAmbulance and site‑specific modifiers generally do not affect provider reimbursement.

Ambulance modifiersExamples (origin/destination indicators): D, E, G, H, I, J, N, P, R, S, X and others — used to denote transport locations; do not affect reimbursement.

Site‑specific modifiersE1‑E4, FA/F1‑F9, TA/T1‑T9, LT/RT, LC/LD/RC — described in Site‑Specific Modifiers section; do not affect provider reimbursement.

inv-16: E1-E4 — anatomic modifiers associated with the eyelid

E1‑E4Anatomic modifiers associated with the eyelid; CPT range where may apply: 10021‑68899.

UseDo not affect provider reimbursement; used to indicate eyelid anatomic location when applicable.

ScopeApplicable to specified CPT surgical ranges per modifier table.

inv-17: FA, F1-F9 — anatomic modifiers associated with the fingers

FA, F1‑F9Anatomic modifiers associated with the fingers; CPT range where may apply: 10021‑64999.

UseDo not affect provider reimbursement; indicate finger‑specific anatomic site when appended to applicable CPT codes.

ScopeApplicable to specified CPT surgical ranges per modifier table.

inv-18: TA, T1-T9 — anatomic modifiers associated with the toes

TA, T1‑T9Anatomic modifiers associated with the toes; CPT range where may apply: 10021‑64999.

UseDo not affect provider reimbursement; indicate toe‑specific anatomic site when appended to applicable CPT codes.

ScopeApplicable to specified CPT surgical ranges per modifier table.

inv-19: LT — Left Side

LTLeft Side — CPT range where modifier may apply: 10021‑69979.

UseSite indicator used to designate left side; does not affect provider reimbursement per policy.

ApplicabilityApplicable to the CPT ranges noted in the Site‑Specific Modifiers table.

inv-20: RT — Right Side

RTRight Side — CPT range where modifier may apply: 10021‑69979.

UseSite indicator used to designate right side; does not affect provider reimbursement per policy.

ApplicabilityApplicable to the CPT ranges noted in the Site‑Specific Modifiers table.

inv-21: LC — Left circumflex coronary artery

LCLeft circumflex coronary artery — CPT range where modifier may apply: 92978‑92984, 92995‑92996.

UseCoronary artery site indicator; does not affect provider reimbursement per policy.

ApplicabilityUsed with specific cardiac procedure CPT ranges as listed in the Site‑Specific Modifiers table.

inv-22: LD — Left anterior descending coronary artery

LDLeft anterior descending coronary artery — CPT range where modifier may apply: (see Site‑Specific Modifiers table).

UseCoronary artery site indicator; does not affect provider reimbursement per policy.

NoteRefer to the modifier table for specific CPT applicability ranges when appending LD.

inv-23: RC — Right coronary artery

RCRight coronary artery — CPT range where modifier may apply: 92978‑92984, 92995‑92996.

UseCoronary artery site indicator; does not affect provider reimbursement per policy.

ApplicabilityUsed with specific cardiac procedure CPT ranges as listed in the Site‑Specific Modifiers table.