CurrentModa HealthPolicy RPM019
Valid Modifier to Procedure Code Combinations
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Defines Moda Health's clinical editing rules for which procedure code and modifier combinations are valid or required on claims and how denials for invalid or missing modifiers are handled; applies to all providers submitting CMS1500 and UB04/CMS1450 claims to Moda Partners, Inc. and its affiliates.
Policy Summary
PayerModa Health
PolicyValid Modifier to Procedure Code Combinations
Policy CodePolicy RPM019
Change TypeNo material change
Effective DateMay 13, 2026
Last ReviewMay 13, 2026
Next Review DateMay 13, 2026
Key ActionIf a line denies for an invalid procedure/modifier combination submit a corrected claim; denials cannot be resolved by phone or email.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
CMS1500 & CMS1450claim forms covered
Allclaim date applicability
Anyprovider contract scope
>20modifier guidance
Idahostate added 2022
Modifier validity and Editing Rules
Modifier validity and required-modifier editing
Moda Health's stance on modifier/procedure combinations and required modifiers for correct pricing and edit behavior.
Clinical editing identifies invalid modifier/procedure code combinations and detects when a required modifier is missing from a claim line.
If a billed modifier/procedure combination is not allowed in Moda's clinical editing system the line will deny as an invalid modifier combination even when the individual procedure and modifier codes are otherwise separately valid for the date of service; these edits apply to CMS1500 and UB04/CMS1450 claims.
Valid modifier tables are configured from multiple sources (CMS guidelines including MPFSDB modifier indicators, CPT coding guidelines and notes, procedure and modifier definitions, clinically derived guidance and standard billing conventions, and medical specialty society guidance). When sources conflict Moda determines which guidance will be applied.
ALL of the following
Unlisted code exceptions
- Unlisted anesthesia codes: AA, AD, GC, QK, QX, QY, QZ (to indicate whether anesthesia services were shared).
- Unlisted surgical codes: assistant-at-surgery (80, 81, 82, AS), co-surgery (62), team surgery (66), staged/related procedure (58), unplanned return to OR (78), unrelated procedure during postoperative period (79), surgical care only (54), postoperative management only (55), preoperative management only (56).
- Unlisted DMEPOS codes: NU, RR, MS, UE are required to identify status, duration, and frequency.
Our clinical editing also identifies when a modifier or selection of modifiers is required for a specific procedure code; if a required modifier is missing a clinical edit denial will occur (see modifier-specific guidelines for RR, NU, UE requirements).
Denials for invalid modifier combinations require submission of a corrected claim or a written provider appeal with supporting coding guidelines; denials cannot be resolved by phone or email.
Examples from the policy: codes priced as bilateral will deny when reported with modifier 50 (e.g., 58720-50 will deny); some procedures on paired structures may accept LT/RT while others do not, depending on whether the structure is a single left/right paired organ.
Policy history notes
Policy history entries summarize clarifications and non-material updates to modifier guidance.
5/13/2026 — Modifier-specific Guidelines table: added bilateral indicator '2' information for LT & RT; acronyms updated; minor rewording. No policy changes.
9/10/2025 — Added modifier FS valid procedures for clarification. No policy changes.
3/12/2025 — Related Policies updated. Formatting updates. No policy changes.
3/13/2024 — Clarified appropriate & inappropriate modifiers for unlisted codes. Related Policies, Resources, & footnotes updated. Minor rewording. No policy changes.
4/12/2023 — Clarified modifiers LT and RT cannot be combined on the same line item. Coding Guidelines & Sources and Resources updated. No policy changes.
10/12/2022 — Idaho added to Scope. Formatting updates. No policy changes.
Earlier entries — 2/26/2013 initial approval; 12/18/2006 original effective date — policy based on clinical editing software using AMA & CMS coding guidelines.
Modifier-specific Coding Guidance
Modifiers allowed with unlisted codesModifier
| AA | Unlisted anesthesia codes: AA (to indicate whether anesthesia services were shared) |
| AD | Unlisted anesthesia codes: AD (to indicate whether anesthesia services were shared) |
| GC | Unlisted anesthesia codes: GC (to indicate whether anesthesia services were shared) |
| QK | Unlisted anesthesia codes: QK (to indicate whether anesthesia services were shared) |
| QX | Unlisted anesthesia codes: QX (to indicate whether anesthesia services were shared) |
| QY | Unlisted anesthesia codes: QY (to indicate whether anesthesia services were shared) |
| QZ | Unlisted anesthesia codes: QZ (to indicate whether anesthesia services were shared) |
| 80 | Unlisted surgical codes: Assistant-at-surgery (80) |
| 81 | Unlisted surgical codes: Assistant-at-surgery (81) |
| 82 | Unlisted surgical codes: Assistant-at-surgery (82) |
1–10 of 23
1/3
modifier-specific rules and examplesModifierCovered
| 24 | Valid on Evaluation and Management (E/M) procedure codes only; do not use with surgical codes, medicine procedures, diagnostic tests, or procedures |
| 25 | Valid on Evaluation and Management (E/M) procedure codes only; do not use with surgical codes, medicine procedures, diagnostic tests, or procedures |
| 26 | Professional component: considered valid for procedures with a PC/TC indicator of 1 or 6; do not use for indicators 0,2,3,4,5,7, or 9 |
| TC | Technical component: considered valid for procedures with a PC/TC indicator of 1; do not use for indicators 0,2,3,4,5,7,8, or 9 |
| 50 | Valid on codes with a bilateral indicator of 1 or 3; report as a single line item with units = 1; do not use with codes that have bilateral indicator 0,2, or 9 or when the code is already priced bilateral |
| 51 | Considered valid for procedures with a multiple procedure indicator of 2,3,4,5,6, or 7; not eligible for CMT codes 98940-98943 (Moda will deny 98940-98943 with modifier 51) |
| 52 | Reduced services: signifies part of the code description was performed; do not use with E/M codes, when another code describes a lesser service, with all-or-nothing codes, or with unlisted codes |
| 58 | Staged/related procedure: valid for procedures with Global Days indicator of 000,010,090, or ZZZ; not valid with certain Global Days or with E/M, radiology, infusion administration, or other non-surgical codes (example: 99213-58 will deny) |
| 78 | Unplanned return to OR: valid for procedures with Global Days indicator of 000,010,090, or ZZZ; not valid with certain Global Days or with E/M, radiology, infusion administration, or other non-surgical codes (example: 99213-78 will deny) |
| 79 | Unrelated procedure during postoperative period: valid for procedures with Global Days indicator of 000,010,090, or ZZZ; not valid with certain Global Days or with E/M, radiology, infusion administration, or other non-surgical codes (example: 99213-79 will deny) |
1–10 of 19
1/2
Bilateral indicator guidanceModifier
| 2 | If a procedure code is designated as always bilateral (indicator '2') do not use modifiers LT or RT; if the bilateral-coded procedure was performed on one side report with modifier 52 per guidance |
| LT | Left side: only valid for paired body parts; use LT on one line and RT on a separate line if 50 is not appropriate; LT and RT may not be billed together on the same line |
| RT | Right side: only valid for paired body parts; use RT on one line and LT on a separate line if 50 is not appropriate; LT and RT may not be billed together on the same line |
Unlisted codes — general allowance (modifier validity)
General ruleMost modifiers are not considered valid with unlisted codes; unlisted codes are defined on a claim-by-claim basis and therefore do not accept the majority of modifiers.
Allowed — Unlisted anesthesiaAA, AD, GC, QK, QX, QY, QZ (to indicate whether anesthesia services were shared).
Allowed — Unlisted surgical (assistant/co/team)Assistant-at-surgery: 80, 81, 82, AS; Co-surgery: 62; Team surgery: 66.
Allowed — Unlisted surgical (staged/return/unrelated/postop)58 (staged/related procedure); 78 (unplanned return to OR); 79 (unrelated procedure during postoperative period); 54 (surgical care only); 55 (postoperative management only); 56 (preoperative management only).
Allowed — Unlisted DMEPOSNU, RR, MS, UE are required for unlisted DMEPOS codes to identify status, duration, and frequency.
What Providers Must Do
Denial Risk
Remedy invalid modifier-combination denials by corrected claim or appeal
If a line item denies for an invalid procedure/modifier combination, the denial cannot be resolved by phone call or email — submit a corrected claim. If you believe the denial is incorrect, submit a written provider appeal and include supporting coding guidelines; medical records may be required.
- Denials for invalid modifier/procedure combinations must be addressed by submitting a corrected claim.
- Disputed denials require a written provider appeal with supporting coding guidance; Moda may request medical records.
Billing Rule
Submit corrected claim when required modifiers (e.g., NU/RR/UE) are missing
When the contracted fee schedule requires a specific modifier (for example NU, RR, or UE) and that modifier is not billed, the line item will deny for a missing required modifier and a corrected claim must be submitted. Examples: A4233 requires NU; E0296 requires RR; A4618 requires NU, RR, or UE.
- Moda's clinical editing identifies when a modifier from a set is required for a procedure code; missing required modifiers trigger a clinical edit denial.
- If a required modifier is missing the line will deny and a corrected claim must be submitted.
- Specific examples from the contracted fee schedule: A4233→NU; E0296→RR; A4618→NU/RR/UE.
Documentation Required
Verify current policy on Moda Health provider website
Verify the most current reimbursement policies on the Moda Health provider website; printed or saved copies of this policy may be out of date.
- Current policies are available at: https://www.modahealth.com/medical/policies_reimburse.shtml
- Policy history on the site notes recent clarifications and minor wording updates; always confirm online before relying on printed or saved versions.
Definitions and Resources
inv-10: clinical editing
DefinitionAutomated clinical editing that identifies invalid modifier/procedure code combinations and detects when a required modifier is missing on a claim line.
Edit behaviorIf a billed modifier/procedure combination is not allowed in Moda's clinical editing system the line will deny as invalid even if codes are otherwise valid.
Sources for tablesValid modifier tables are configured from CMS guidelines, CPT guidance, procedure/modifier definitions, clinical guidance, and specialty society guidance; conflicts are resolved by Moda.
inv-11: LT / RT
PurposeLT and RT identify procedures performed on the left or right side of paired body parts.
Validity constraintLT/RT modifiers are valid only when the structure is clearly a single left/right paired organ or site; not valid when structure is not clearly paired.
Billing guidanceLT/RT may not be billed together on the same line; follow CMS guidance (use 50 or separate line items as applicable).
inv-12: NU / RR / UE
MeaningsNU = New equipment; RR = Rental; UE = Used durable medical equipment.
RequirementCertain contracted fee schedule codes (including unlisted DMEPOS examples) require NU, RR, or UE to identify equipment status, duration, and frequency.
Denial behaviorIf a required DME modifier is missing on a code that requires it, the line item will deny and a corrected claim must be submitted.
inv-13: Resources
Primary sourcesMultiple CMS manuals and transmittals (e.g., MPFSDB indicators, Medicare Claims Processing Manual) used to configure valid modifier tables.
Coding referencesCPT coding guidelines, procedure and modifier definitions, and specialty society guidance are referenced when building tables.
Published resourcesAdditional references include CMS transmittals, coding textbooks, and published articles on modifier usage and paired organ coding.
Policy Summary
PayerModa Health
PolicyValid Modifier to Procedure Code Combinations
Policy CodePolicy RPM019
Change TypeNo material change
Effective DateMay 13, 2026
Last ReviewMay 13, 2026
Next Review DateMay 13, 2026
Key ActionIf a line denies for an invalid procedure/modifier combination submit a corrected claim; denials cannot be resolved by phone or email.
SourceLink
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