CurrentFlorida BluePolicy 10-011

Modifier Reference

Defines Florida Blue's billing, coding, and reimbursement guidance for CPT/HCPCS modifiers on professional claims and who it affects (providers submitting CMS-1500 or equivalent claims across all lines of business).

Policy Summary

PayerFlorida Blue

PolicyModifier Reference

Policy CodePolicy 10-011

Change TypeMultiple added and revised modifiers

Effective DateMay 14, 2010

Next Review Date

Key ActionReport appropriate anatomic modifiers (e.g., LC, LD, LM, RC, RI) and use modifier SL to identify vaccines obtained at no cost; vaccine product will not be reimbursed though administration may be.

SourceLink

POLICY UPDATE CHANGES

Modifiers CO and CQ added with reference to Physical Therapy Assistant and Occupational Therapy Assistant Services payment policy.

Modifier 93 added with reference to Virtual Visit payment policy.

Modifiers SH and SJ added with reference to Multiple Procedure Reduction Home Infusion Therapy Per Diem payment policy.

Clarifying language added to indicate this policy applies to billing for services on a CMS-1500 or equivalent claim form.

Modifiers CT, FX, and FY added.

Modifier FT added with reference to Global Surgery Package payment policy.

Modifiers SL added (vaccine cost identification and non-reimbursement guidance).

up to 4modifiers accepted per claim line

first & secondmodifier positions that affect reimbursement

50%allowed amount reduction (52/53)

70%

allowed amount (54/78)

2025references updated through

Modifier Coverage and Reimbursement Rules

Modifier reimbursement rules

Reimbursement effects and documentation expectations for modifiers

Modifiers affecting reimbursement should be submitted in the first and second position on paper and electronic claims; up to four modifiers are accepted per claim line.

Documentation and billing expectations

Modifier 22 (Increased Procedural Services): clinical records may be required to support use.
Modifier 25 (Significant, Separately Identifiable E/M): use only with E/M codes and documentation is required.

Allowed amount adjustments

Modifier 52 (Reduced Services): allowed amount is reduced by 50%.
Modifier 53 (Discontinued Procedure): allowed amount is reduced by 50%.
Modifier 54 (Surgical Care Only): allowed amount is 70% of the normal fee schedule amount.
Modifier 78 (Unplanned Return to OR by Same Physician): allowed amount is 70% of the normal fee schedule amount.
Modifier 55 (Postoperative Management Only): allowed amount is 30% of the normal fee schedule amount.

Assistant and co-surgeon reimbursement

Modifiers 80, 81, 82 (Assistant Surgeon): allowed amount is 16% of the ordinary fee schedule.
Modifier 62 (Two Surgeons): each reimbursed at 62.5% of usual fee schedule.
Modifier AS (PA/NP/CNS assistant at surgery): allowed amount is 13.6% of ordinary fee schedule.

Anesthesia modifier rules

Time-based anesthesia services require an anesthesia modifier (for example QK, QX, QS).
Certain CRNA or physician-directed anesthesia services reported with applicable modifiers are reimbursed at 50% of the fee schedule rate.
Modifier AD (medical supervision >4 concurrent anesthesia procedures) is not recognized by Florida Blue for reimbursement.

Therapy assistant modifiers

Modifiers CO (OT assistant) and CQ (PT assistant): reimbursement for services provided by assistants will be reduced by 15%.

Equipment and technical component modifiers

For Medicare Advantage claims, modifier CT (non‑NEMA XR‑29 compliant CT) reduces the technical component RVU by 15%.
Modifier FX (X‑ray film) and similar technical component modifiers may carry TC component adjustments per applicable guidance.

Telemedicine and service-type modifiers

Modifiers 93 (audio-only) and 95 (audio-video) identify telemedicine services as referenced in the Virtual Visits policy.
Modifiers 96 and 97 identify habilitative and rehabilitative services respectively and should be reported as applicable.

Modifier coverage criteria

Stated billing/reimbursement criteria for specific modifiers

SL: Modifier SL must be used to identify vaccines obtained at no cost to the provider. Florida Blue will not reimburse the vaccine(s) obtained at no cost; administration may be reimbursed in accordance with the patient's benefit coverage.

P1–P6: Physical status (P) modifiers are documented for anesthesia physical status but additional reimbursement is not provided for these modifiers.

QX/Q4/QY/QZ/QK/QS (anesthesia-related modifiers): Time-based anesthesia services require an anesthesia modifier; certain CRNA or physician-directed services reported with applicable anesthesia modifiers are reimbursed at 50% of the fee schedule when specified (e.g., QX reported by a CRNA with medical direction is reimbursed at 50%).

TC: Technical component (TC) should be reported when the technical component is provided separately; facility/technical reporting and physician professional component reporting follow the applicable component guidance.

NCCI and distinct service modifiers

Modifier Codes and Coding Guidance

Modifiers (general)mixed

CPT/HCPCS modifiers

Valid modifiers and their descriptions found in current CPT and HCPCS coding books; used to indicate altered services without changing code definition.

Specific modifiers and billing guidancemixed

22	Increased Procedural Services; not for E/M; clinical records may be required.
24	Unrelated E/M Service by the Same Physician during a Postoperative Period; clinical records may be required.
25	Significant, Separately Identifiable E/M on same day as procedure; use with E/M codes only; documentation required.
26	Professional component; report when professional component provided separately; physicians reimbursed for professional component only.
33	Preventive Services; may be used to identify preventive services.
47	Anesthesia by Surgeon; anesthesia performed by surgeon is not payable and should not be reported.
50	Bilateral Procedure; report on separate lines with LT/RT or single line with modifier 50 as allowed.
51	Multiple Procedures; not to be appended to add-on codes; modifier 51 not required to identify procedures to be reduced under multiple surgical procedure reduction.
52	Reduced Services; allowed amount reduced by 50%.
53	Discontinued Procedure; allowed amount reduced by 50%.

1–10 of 37

1/4

Documented modifiersmixed

LC, LD, LM, RC, RI	Anatomic modifiers associated with coronary arteries
LT, RT	Left and Right side identifiers
P1-P6	Physical status modifiers (anesthesia) — no additional reimbursement
QK, QL, QS, QX	Anesthesia-related modifiers with reimbursement guidance (certain reported at 50% when applicable)
SH, SJ	Second/Third or more concurrently administered infusion therapy modifiers
SL	State supplied vaccine modifier — identifies no-cost vaccine product; vaccine product not reimbursed
TC	Technical component modifier
XE, XP, XS, XU	NCCI-associated distinct service modifiers; should not be reported with E/M codes

inv-06: max_modifiers_per_line

Maximum modifiers accepted per claim lineUp to 4 modifiers may be submitted on a single claim line.

Positions that affect reimbursementModifiers that affect reimbursement should be submitted in the first and second positions on paper and electronic claims.

Claim form applicabilityThis policy applies to billing on a CMS-1500 or equivalent claim form.

inv-07: priority_positions

Priority modifier positionsFirst and second modifier positions affect reimbursement and should be used for modifiers that change payment.

Submission guidance

Provider Billing Actions and Requirements

Note

Policy status and limits

THIS PAYMENT POLICY IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT; benefits are determined by the group contract and member certificate in effect at the time services were rendered.

Billing Rule

Report coronary artery anatomic modifiers (LC, LD, LM, RC, RI)

Report the appropriate coronary artery anatomic modifiers (LC, LD, LM, RC, RI) when identifying coronary artery procedures and follow the Anatomical Modifier Requirement Policy and NCCI guidance.

Use LC/LD/LM for left coronary artery sites and RC/RI for right coronary artery sites as applicable.
Refer to the Anatomical Modifier Requirement Policy and National Correct Coding Initiative for additional billing standards.

Key Definitions

inv-13: modifier

DefinitionModifier: a means to indicate a service or procedure was altered by specific circumstances without changing its definition or code.

Source of valid modifiersValid modifiers and their descriptions are found in the current CPT and HCPCS coding books.

PurposeModifiers provide additional information needed for proper payment of claims when a service’s circumstances are altered.

inv-14: same provider

DefinitionSame provider: all physicians and/or other health care professionals reporting under the same Federal Tax Identification Number for the purposes of this policy.

Policy scopeUsed to determine when modifiers such as Repeat Procedure or Assistant Surgeon rules apply across individuals reporting under the same TIN.

Policy Summary

PayerFlorida Blue

PolicyModifier Reference

Policy CodePolicy 10-011

Change TypeMultiple added and revised modifiers

Effective DateMay 14, 2010

Next Review Date

SourceLink

On This Page

XE/XP/XS/XU: Modifiers used to indicate distinct procedural services should be applied per NCCI guidance and not reported to bypass E/M restrictions.

59: Modifier 59 (Distinct Procedural Service) should be used per NCCI and is not to be combined improperly with E/M codes.

Submit modifiers in correct order on both paper and electronic claims to ensure proper reimbursement.

Accepted modifiers per lineUp to four modifiers are accepted per claim line; prioritize reimbursement‑affecting modifiers in positions one and two.

inv-08: Anesthesia reimbursement reduction

Anesthesia modifiers with reduced reimbursementCertain CRNA- or physician-directed anesthesia services reported with applicable modifiers (e.g., QX, QK/QX equivalents) are reimbursed at 50% of the fee schedule.

Time-based requirementTime-based anesthesia services require an appropriate anesthesia modifier (e.g., QK, QX, QS) to be reported.

See related policyRefer to the Anesthesia Services payment policy for full guidance on modifier use and reimbursement implications.

Billing Rule

State‑supplied vaccine reporting (modifier SL)

Use modifier SL to identify vaccines obtained at no cost to the provider; Florida Blue will not reimburse vaccine product obtained at no cost but may reimburse administration per the patient's benefit coverage.

Append modifier SL to vaccine product lines obtained at no cost to the provider.
Administration of the vaccine may be reimbursed according to the member's benefits even when SL is reported.

Billing Rule

Anesthesia modifiers required for time‑based services (QX/QS/etc.)

Time‑based anesthesia services must include the appropriate anesthesia modifier (e.g., QX, QS, QK) when reported; certain CRNA or physician‑directed services reported with these modifiers are reimbursed at 50% of the fee schedule.

Report an anesthesia modifier for time‑based anesthesia services.
Services reported by a CRNA with medical direction (QX) or by a physician for medical direction may be reimbursed at 50% when indicated.

Claim applicabilityApplies to billing on a CMS-1500 or equivalent claim form as noted in the policy.

inv-15: Anatomic modifiers associated with coronary arteries

Listed anatomic modifiersLC, LD, LM, RC, RI

Use caseThese modifiers are associated with coronary arteries and should be reported when identifying coronary artery procedures.

Reference guidanceRefer to the Anatomical Modifier Requirement Policy and NCCI for further billing standards and reimbursement rules.

inv-16: State supplied vaccine modifier

Modifier codeSL

PurposeUsed to identify vaccine(s) obtained at no cost to the provider (state‑supplied vaccines).

Reimbursement effectFlorida Blue will not reimburse vaccine(s) obtained at no cost to the provider; administration may be reimbursed per the patient’s benefit coverage.

inv-17: Technical component modifier

Modifier codeTC

MeaningTechnical component: reported when the technical component of a service is provided separately from the professional component.

Billing effectReport TC when the technical component is billed separately; physicians typically are reimbursed for the professional component only when TC is used.