CurrentIowa Department of Health and Human ServicesPolicy N/A
Procedure Code Modifiers
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Defines descriptors and reimbursement impacts for procedure code modifiers used by Iowa Medicaid and indicates payment adjustments by modifier and service category; applies to providers billing Iowa Department of Health and Human Services (Medicaid).
Policy Summary
PayerIowa Department of Health and Human Services
PolicyProcedure Code Modifiers
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJun 11, 2026
Last ReviewJun 11, 2026
Next Review DateN/A
Key ActionObtain prior authorization to permit payment above the fee schedule for services billed with modifier U5.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
~70+modifiers and entries enumerated across document
100%–16%range of explicit percentage reimbursement impacts shown
DME, Anesthesia, Audiology, LEAservice categories with specific modifier tables
Somereferences to Medicare indicators or fee schedule rules
Payment and Medicare-referenced Determinations
Payment-impact modifiers with authorization/billing implications
Modifiers that affect payment percentage or allow payment above the fee schedule when prior authorized.
Modifier U5 — Medicaid-defined modifier that allows payment above the fee schedule amount if the service is prior authorized.
Modifier UE — Used equipment; reimbursed at 80.00% of the fee schedule amount.
Modifier BA — Item furnished in conjunction with parenteral enteral nutrition (PEN) services; reimbursed at 69.40% of the fee schedule amount.
Modifier CG — Policy criteria applied (example reference HCPCS E0627); reimbursement as specified by applicable DME policy criteria and HCPCS rules.
Medicare-referenced payment determinations
Modifiers where reimbursement is determined by Medicare-assigned percentages or indicators.
Modifier 50 — Bilateral procedure. Reimbursement determined by the Medicare-assigned HCPCS bilateral indicator: indicator '1' = 150.00% of fee schedule amount; indicator '3' = 200.00% of fee schedule amount.
Modifiers 54 and 55 — Surgical care only (54) and post-operative management only (55). Reimbursement based on the pre‑op/intra‑op (for 54) and post‑op (for 55) percentages assigned to the CPT code by Medicare.
Modifier 78 — Unplanned return to/or for related procedure during the post‑op period; reimbursement based on the intra‑op percentage assigned to the CPT code by Medicare.
Modifier Code Tables and Coding Notes
Anesthesia ModifiersModifier
| AA | Anesthesia service personally performed by physician; reimbursed at 100.00% of fee schedule amount |
| AD | Medical supervision by a physician for more than 4 concurrent procedures; reimbursed at 50.00% of fee schedule amount |
| QK | Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals; reimbursed at 50.00% of fee schedule amount |
| QX | CRNA service with medical direction by a physician; reimbursed at 50.00% of fee schedule amount |
| QY | Medical direction of one certified registered nurse anesthetist; reimbursed at 50.00% of fee schedule amount |
| QZ | CRNA service without medical direction by a physician; reimbursed at 80.00% of fee schedule amount |
Audiologist / Hearing Aid Dealer ModifiersModifier | HCPCS
| 52 | Reduced services - Test applied to one ear instead of two ears; Dates of Service prior to 10/01/17: 90.00% of fee schedule amount; Dates of Service on or after 10/01/17: 50.00% of fee schedule amount |
| U3 | Nursing home dispensing fee (HCPCS V5160 and V5241); reimbursed at 110.00% of fee schedule amount |
DME ModifiersModifier | HCPCS
| BA | Item furnished in conjunction with parenteral enteral nutrition (PEN) services; reimbursed at 69.40% of fee schedule amount |
| CG | Policy criteria applied (example HCPCS E0627 referenced) |
| UE | Used equipment; reimbursed at 80.00% of fee schedule amount |
| U5 | Medicaid-defined modifier allowing payment above the fee schedule amount if service is prior authorized |
Local Education/Area Education/Infant & Toddler ModifiersModifier
| GN | Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care; reimbursed at 100.00% of fee schedule amount |
| GO | Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care; reimbursed at 100.00% of fee schedule amount |
| GP | Service delivered personally by a physical therapist or under an outpatient therapy plan of care; reimbursed at 100.00% of fee schedule amount |
| HO | Master's degree level; Local Education Agency: 72.00% of fee schedule amount; All other providers: 80.00% of fee schedule amount |
| UA | Medicaid-defined modifier (Audiologist); referenced 165.00% and 97.00% of fee schedule amount in Medicaid contexts |
Other/Common ModifiersModifier | HCPCS
| 22 | Increased procedural services; reimbursed at 110.00% of fee schedule amount |
| 50 | Bilateral procedure; reimbursement depends on Medicare bilateral indicator: indicator '1' = 150.00% of fee schedule amount; indicator '3' = 200.00% of fee schedule amount |
| 52 | Reduced services; Dates of Service prior to 10/01/17: 90.00% of fee schedule amount; Dates of Service on or after 10/01/17: 50.00% of fee schedule amount |
| 53 | Discontinued procedure; reimbursement based on review of submitted documentation |
| 54 | Surgical care only; reimbursement based on the pre-op and intra-op percentage assigned to the CPT code by Medicare |
| 55 | Post-op management only; reimbursement based on the post-op percentage assigned to the CPT code by Medicare |
| 62 | Two surgeons; reimbursed at 62.50% of fee schedule amount |
| 66 | Surgical team; reimbursement based on review of submitted documentation |
| 73 | Discontinued outpatient hospital/ASC procedure prior to specified point; reimbursed at 50.00% of ASC level fee schedule amount |
| 78 | Unplanned return for related procedure during post-op period; reimbursement based on the intra-op percentage assigned to the CPT code by Medicare |
1–10 of 16
1/2
inv-08: Bilateral payment multiplier by Medicare indicator
Medicare bilateral indicator = '1'Payment = 150.00% of fee schedule amount
Medicare bilateral indicator = '3'Payment = 200.00% of fee schedule amount
Determination methodUses HCPCS codes' bilateral indicator as assigned by Medicare to select multiplier
Authorization and Billing Requirements
Prior Authorization
Prior authorization required to bill above-fee amount (modifier U5)
Use modifier U5 on DME claims when you have an approved prior authorization to request payment above the fee schedule amount.
- U5 is a Medicaid-defined modifier that allows payment above the fee schedule amount when the service is prior authorized.
- Attach or reference the prior authorization approval number on the claim per payer instructions.
Modifier Definitions and Short Notes
inv-10: AA — Anesthesia service personally performed by physician
AAAnesthesia service personally performed by physician; reimbursed at 100.00% of fee schedule amount
ADMedical supervision by a physician for >4 concurrent procedures; reimbursed at 50.00% of fee schedule amount
QK/QX/QYMedical direction/CRNA with direction scenarios; reimbursed at 50.00% of fee schedule amount (QK, QX, QY)
QZCRNA service without medical direction by a physician; reimbursed at 80.00% of fee schedule amount
inv-11: UE — Used equipment; paid at 80.00% of fee schedule amount
UEUsed equipment; reimbursed at 80.00% of fee schedule amount
BAItem furnished with parenteral enteral nutrition (PEN) services; reimbursed at 69.40% of fee schedule amount
CGPolicy criteria applied (example HCPCS E0627 referenced)
inv-12: 50 — Bilateral procedure; payment uses Medicare bilateral indicator to determine multiplier
50 (bilateral) - indicator '1'150.00% of fee schedule amount
50 (bilateral) - indicator '3'200.00% of fee schedule amount
ApplicationMultiplier applied per HCPCS codes' bilateral indicator assigned by Medicare
inv-13: U5 — Medicaid-defined modifier that allows payment above the fee schedule if the service is prior authorized
U5Medicaid-defined modifier that allows payment above the fee schedule amount if the service is prior authorized
Prior authorization requirementPayment above fee schedule is permitted only when the service has prior authorization
ScopeApplies to DME services where U5 is billed to indicate prior-authorized above-fee payment
Policy Summary
PayerIowa Department of Health and Human Services
PolicyProcedure Code Modifiers
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJun 11, 2026
Last ReviewJun 11, 2026
Next Review DateN/A
Key ActionObtain prior authorization to permit payment above the fee schedule for services billed with modifier U5.
SourceLink
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