ModifiedHumanaPolicy CP2013101

Common CPT and HCPCS Modifiers

Defines Humana's Medicare Advantage guidance for reporting frequently used CPT and HCPCS modifiers, how they affect claims processing and reimbursement, and expectations for documentation; applies to providers submitting claims for Humana Medicare Advantage products.

Policy Summary

PayerHumana

PolicyCommon CPT and HCPCS Modifiers

Policy CodePolicy CP2013101

Change TypeAdministrative header revision (revision date updated)

Effective DateFeb 1, 2015

Next Review DateN/A

Key ActionEnsure documentation supports any submitted modifier to avoid claim denial or payment recovery.

SourceLink

POLICY UPDATE CHANGES

Revision date updated to 01/2026 in document header.

~60+modifiers listed (approx)

Medicare Advantageproduct line

Requireddocumentation requirement

~10+modifiers with notes here

Availity/edits/resourcesprovider resources

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.

Modifier Coverage Guidance

Modifier coverage guidance (selected)

Modifier-specific coverage stance and quick references (representative examples from the document):

Modifier 22: Increased procedural services — Service allowed when documentation supports; reimbursement percentage determined on an individual claim basis.

Modifier 24: Unrelated E/M during postoperative period — Allowed when documentation supports; no payment adjustment.

Modifier 25: Significant, separately identifiable E/M on same day as procedure — Allowed when documentation supports; professional claims only; no payment adjustment.

Modifier 50: Bilateral procedure — Report when an MPFS bilateral indicator 1 code is performed bilaterally; report on one claim line with a unit of 1; Medicare Advantage reimbursement = 150% of the amount otherwise allowed for MPFS bilateral indicator 1 codes.

Modifier 51: Multiple procedures — Informational only; MPPR applies when appropriate regardless of whether modifier 51 is appended.

Modifier 52: Reduced services — Report on professional or facility claims; do not report with an E/M service; Medicare Advantage reimbursement = 50% of the amount otherwise allowed.

Modifier 53: Discontinued services — Report on professional claims only; do not report on an E/M service; Medicare Advantage reimbursement ≈ 29% of the amount otherwise allowed.

Modifier 78: Unplanned return to the OR for related procedure in postoperative period — Report on professional claims only; reimbursement per MPFS guidance for related return to OR.

Modifier 95: Synchronous telemedicine (real-time audio/video) — Allowed when telehealth requirements are met; informational only; no payment adjustment when allowed.

Modifier CT (XR-29 noncompliant): Technical component reduction — When CT equipment does not meet NEMA XR-29 attributes, technical component is reimbursed at 85%.

Modifiers JW / JZ: Drug amount discarded / zero discarded — Allowed when appropriate; follow reporting rules (separate lines for discarded vs administered amounts for JW; do not report JW and JZ together).

Modifier KX: Indicates CMS-specified medical policy requirements have been met — Use where required; service allowed when appropriate with no adjustment to the amount allowed.

Per-modifier reimbursement notes

Per-modifier Medicare Advantage reimbursement guidance and quick references included:

Modifiers NR / NU (new when rented / new equipment) — Medicare Advantage reimbursement: purchase rate minus any previously allowed rental amounts; do not report NR/NU for DMEPOS items that cannot be purchased (e.g., oxygen equipment).

Modifiers PA / PB / PC (wrong body part / wrong patient / wrong surgery) — Medicare Advantage reimbursement: Not reimbursed; report appropriate modifier when such events occur.

Modifiers QG / QR / QE / QF (oxygen-related) — Medicare Advantage reimbursement: examples include QG and QR = 150% of the amount otherwise allowed for higher stationary oxygen LPM; QE = 50% of the amount otherwise allowed; QF = amount allowed is the higher of 50% of stationary equipment monthly rental or 100% of the portable equipment monthly rental.

Modifiers QK / QX / QY / QZ (anesthesia/CRNA direction) — Medicare Advantage reimbursement: QK, QX, QY = 50% of the amount otherwise allowed (with incompatibility notes: do not report QK with QX/QY/QZ and do not report QX/QY with QK/QZ); QZ = 100% of the amount otherwise allowed.

CPT, HCPCS and Modifier Coding

Representative CPT and HCPCS modifiers describedmixed

22	Increased procedural services; report on professional claims only; do not report with E/M.
24	Unrelated E/M during postoperative period; service allowed when appropriate; no payment adjustment.
25	Significant, separately identifiable E/M on same day as procedure; documentation required; professional claims only.
26	Professional component only; report with global service to bill only professional component.
50	Bilateral procedure; report on one claim line with unit of 1 when MPFS bilateral indicator 1 code performed bilaterally; Humana encourages modifier 50 for bilateral indicator 1 codes.
51	Multiple procedures; MPPR applies when appropriate; modifier 51 informational only.
52	Reduced services; reimbursement approximately 50%; do not report with an E/M service.
53	Discontinued services; reimbursement approximately 29%; report on professional claims only; do not report on E/M services.
54	Surgical care only; Medicare advantage reimbursement per MPFS.
55	Postoperative management only; Medicare advantage reimbursement per MPFS; report on professional claims only.

1–10 of 28

1/3

example modifiers describedCPT

KX	Requirements specified in the medical policy have been met.
LT/RT	Left/Right side modifiers used to identify procedures/items performed on left or right side; Humana encourages modifier 50 for bilateral indicator 1 codes but accepts LT/RT; do not report LT/RT when a more descriptive anatomical modifier applies.
50	Bilateral procedure modifier; report when MPFS bilateral indicator 1 code is performed bilaterally; report on one claim line with unit of 1.
XE/XP/XS/XU	Distinct service modifiers intended as alternatives to modifier 59; should be used instead of modifier 59 when appropriate; do not report both 59 and an X-series modifier on same claim line; do not report XE/XP/XS/XU with an E/M service.
TA-T9	Toe modifiers; when reporting a toe modifier do not also report modifier LT or RT; for bilateral toe procedures report modifier 50 and the toe modifiers.

Reimbursement adjustments or percentages — examples

Modifier 52Reduced services — Medicare Advantage reimbursement = 50% of the amount otherwise allowed.

Modifier 53Discontinued services — Medicare Advantage reimbursement = 29% of the amount otherwise allowed; report on professional claims only.

Assistant surgeon modifiers (80/82/AS)Assistant at surgery reimbursement ≈ 16% of the amount otherwise allowed (modifier 82 and AS listed at ~16%).

Modifier 50Bilateral procedure — Medicare Advantage reimbursement = 150% of the amount otherwise allowed for MPFS bilateral indicator 1 codes; report on one claim line with unit of 1.

Modifier CT (technical reduction)CT technical component on non‑XR‑29 equipment reimbursed at 85% of the amount otherwise allowed for the technical component.

Required Provider Actions and Billing Rules

Denial Risk

Modifier review and potential denial

Claims with modifiers are subject to review; inappropriate modifier submission may result in denial or recovery of payment. Humana requires use of CPT and HCPCS modifiers when appropriate. If a modifier is submitted, the claim is reviewed to ensure the procedure code and modifier combination is correct and the modifier was necessary.

Humana plans require CPT/HCPCS modifiers when appropriate.
Inappropriate or unsupported modifier use may result in denial or recovery.

Documentation Required

Documentation requirement

Documentation of services must support any submitted modifier. Maintain contemporaneous medical record documentation that clearly justifies the need for and appropriateness of the modifier(s) billed.

Documentation should describe why the modifier was necessary and support distinct encounters, practitioners, structures, laterality, etc.

Key Definitions and Modifier Meanings

Modifier — definition

DefinitionA modifier is a two-character code appended to a CPT or HCPCS code to clarify the services rendered without changing the procedure code; modifiers facilitate editing, increase reimbursement accuracy and improve coding consistency.

PurposeUsed to clarify circumstances of the service (e.g., bilateral service, reduced service, professional/technical component) to aid claims processing and reimbursement.

Documentation requirementDocumentation of services must support any submitted modifier.

Modifier review — Humana review and denial consequence

Humana reviewIf a modifier is submitted, the claim is subject to review to ensure the procedure code and modifier combination is correct and the modifier was necessary.

Denial or recovery