ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Use and reimbursement impact of CPT and HCPCS modifiers

Defines Neighborhood Health Plan of Rhode Island's rules for accepting and reimbursing claims with CPT/HCPCS modifiers and which lines of business the policy applies to.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUse and reimbursement impact of CPT and HCPCS modifiers

Policy CodePolicy N/A

Change TypeAdded and revised modifier reimbursement and documentation guidance

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and authorization prior to rendering services; retain medical documentation to support modifier use.

SourceLink

POLICY UPDATE CHANGES

Added Modifiers CQ and CO with reimbursement rates.

Updated policy to include Anesthesia and Locum Tenens modifiers and updated assistant surgeon documentation requirements.

100%modifier 25 reimbursed

120%modifiers 22/23 reimbursed

69%modifiers 54/58/78 reimbursed

20%assistant surgeon (80/82) reimbursed

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.

therapy assistant (CO/CQ) reimbursed

62%modifier 66 reimbursed

Coverage and Documentation Requirements for Modifiers

inv-01: Modifier usage and documentation requirements

Modifiers are accepted when medically necessary and properly documented. Payment or allowance may depend on whether the modifier indicates an inclusive portion of a global surgical package or a separately reportable service.

Modifiers must be appropriate to the CPT/HCPCS procedure code(s) reported and supported in the medical record; Neighborhood reserves the right to request medical records to substantiate billed services and medical necessity.

Documentation requirements (one or more may apply)

Modifier 22 (Unusual procedural services): provider must document reason for additional work including increased intensity, time, technical difficulty, severity, or physical/mental effort required.
Modifier 25 (Significant, separately identifiable E/M same day): use only with E/M codes and document a significant, separately identifiable E/M service performed by the same physician on the same day as a procedure.
Modifiers 58 and 78 (Return to OR/staged/related procedures): medical records may be required; bill the procedure code that best describes the work performed; full payment allowed for treatment of complications by another physician (do not bill with 78).
Modifiers 54, 55, 56 (Portions of global surgical package): use only for procedures with a 90-day global period (not 0- or 10-day global periods); documentation must identify which portion of the global package was performed and, if applicable, a notation agreeing to transfer postoperative care when modifier 54 is used.
Modifiers 62 and 66 (Co-surgeons/team): require appropriate documentation establishing medical necessity for two surgeons or a team; payment for assistants generally not allowed without clear, compelling documentation.
Modifiers 80/81/82/AS (Assistants at surgery): assistant presence must be medically necessary; documentation should clearly describe the assistant’s role; modifier AS is for non-physician assistants and should not be billed by a physician.

Claims and coding must meet CPT, ICD-10-CM and HCPCS standards and be submitted within contractual timely filing guidelines; services are subject to contract terms, edits, authorization policies and audit.

inv-02: Modifier reimbursement and billing rules

Reimbursement for services billed with modifiers is governed by contractually determined allowance percentages, applicable coding and documentation rules, member coverage and authorization requirements. Payments are subject to claim edits and audit.

Payments for modifier-appended services follow Neighborhood’s contracted rates or standard modifier allowances; specific modifier reimbursement percentages are applied as listed in the coding tables and are subject to provider contracts and claim edits.

Examples of modifier reimbursement percentages

Modifier 22 and 23: reimbursed at 120% of the fee schedule when documentation supports additional work or anesthesia-related services.
Modifier 25: reimbursed at 100% of the fee schedule when criteria for a significant, separately identifiable E/M service are met.
Modifiers 54, 58, 78: typically reimbursed at 69% (subject to contract) when appropriately used for portions of the global surgical package or related postoperative procedures.

Accepted Modifiers, Definitions, and Reimbursement Percentages

Accepted modifiers with reimbursement percentagesmixedCovered

22	Unusual procedural services; 120% of fee schedule
23	Unusual anesthesia; 120% of fee schedule
25	Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service; 100% of fee schedule
26	Professional component; 30% of fee schedule
50	Bilateral procedure; (Refer to the Multiple Procedures Payment Policy)
51	Multiple procedures; (Refer to the Multiple Procedures Payment Policy)
52	Reduced services; 15% of fee schedule
53	Discontinued procedure; 20% of fee schedule
54	Surgical care only; 69% of fee schedule
55	Postoperative care only; 21% of fee schedule

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Modifiers with reimbursement percentagesmixedCovered

66	Surgical team — reimbursed at 62% of fee schedule
73	Discontinued outpatient hospital/ASC procedure prior to anesthesia — reimbursed at 50% of fee schedule
78	Unplanned return to OR related procedure — reimbursed at 69% of fee schedule
79	Unrelated procedure by same provider during postoperative period — reimbursed at 100% of fee schedule
80	Assistant surgeon — reimbursed at 20% of fee schedule
81	Minimum assistant surgeon — reimbursed at 15% of fee schedule
82	Assistant surgeon when qualified resident not available — reimbursed at 20% of fee schedule
91	Repeat clinical diagnostic laboratory test — reimbursed at 100% of fee schedule
AS	Physician assistant; nurse practitioner — reimbursed at 13.60% of fee schedule
CO	Outpatient occupational therapy assistant — reimbursed at 85% of fee schedule

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Global period applicability

ApplicabilityModifiers 54, 55 and 56 apply when only part of the global surgical package is performed and should be added to procedures with a 90-day global period only (not for 0- or 10-day global periods).

Use within same group/covering physicianDo not use Modifiers 54, 55 or 56 when the physicians performing surgical, post- or pre-operative care are within the same group or are a covering physician.

Modifier 54 specificsModifier 54 (Surgical care only) indicates the physician performed only the intra-operative portion; record must note transfer of postoperative care to another physician/provider.

Modifier 55 specificsModifier 55 (Postoperative management only) indicates the physician performed only postoperative care after another physician performed the surgery; add only after the initial postoperative visit and used after hospital discharge.

Modifier 56 specificsModifier 56 (Preoperative management only) indicates the physician provided only the preoperative evaluation and is used rarely and only on surgical codes.

Provider Billing, Authorization, and Documentation Actions

Documentation Required

Prior verification and documentation

It is the provider's responsibility to verify member eligibility, coverage, and any applicable authorization criteria before rendering services. Medical necessity must be established for all services; Neighborhood may rely on NCDs, LCDs, industry-accepted criteria (e.g., InterQual), Rhode Island EOHHS guidance, and Neighborhood Clinical Medical Policies when determining medical necessity. Providers should have supporting documentation available at the time of service and upon request. Medical notes may be required for certain modifiers or claims to determine medical necessity.

Verify member eligibility and benefits prior to scheduling or providing services.
Confirm whether prior authorization is required and obtain it when indicated.
Maintain complete clinical documentation in the medical record to support services billed and medical necessity.

Prior Authorization

Prior Authorization Reference

Refer to Neighborhood's plan-specific Prior Authorization Reference page for details on services that require prior authorization, submission procedures, and any form or timing requirements. When prior authorization is required, obtain approval before delivering the service to avoid claim denials or member liability.

Modifier Definitions and Related Terms

CPT/HCPCS modifier

DefinitionA CPT/HCPCS modifier is an alphanumeric code appended to a procedure code to indicate a service or circumstance that modifies the procedure performed and may affect reimbursement or claim processing.

Accepted useNeighborhood accepts all standard CPT and HCPCS modifiers when submitted in accordance with the appropriate procedure code(s).

Impact of incorrect useAbsence of an appropriate modifier or use of an inappropriate modifier may result in claim denial or reimbursement impact.

Modifier 22

PurposeModifier 22 indicates the procedure was substantially greater than typical and may warrant additional reimbursement.

Documentation required

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUse and reimbursement impact of CPT and HCPCS modifiers

Policy CodePolicy N/A

Change TypeAdded and revised modifier reimbursement and documentation guidance

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and authorization prior to rendering services; retain medical documentation to support modifier use.

SourceLink

On This Page

Modifier 66 (Surgical team): reimbursed at 62% of the fee schedule.

Modifiers 73 (discontinued outpatient/ASC prior to anesthesia): reimbursed at 50% of the fee schedule.

Modifier 79, 91, Q6 and certain locum tenens/other modifiers: reimbursed at 100% of the fee schedule when applicable and supported by documentation.

Assistant surgeon modifiers (80, 82): reimbursed at 20%; modifier 81 at 15%; AS (PA/NP) at 13.60%.

Therapy assistant modifiers CO and CQ: reimbursed at 85% when services are furnished in whole or in part by therapy assistants (operational change added).

Technical component (TC): reimbursed at 70% of the fee schedule.

Billing and documentation rules: append appropriate modifier to the correct code (e.g., do not append 25 to a procedure code), include required medical record documentation to support modifier usage, and follow any plan-specific prior authorization requirements before billing.

Member/contract caveats and audit rights: reimbursement remains subject to member benefit coverage, eligibility, provider contracts, authorization policies, claim payment edit rules, and Neighborhood’s right to audit submitted claims and request records.

Timely filing

Timely filing requirementProviders must submit complete claims for payment within contractually determined timely filing guidelines.

Contractual applicabilityBillable services are subject to contractual agreements where applicable; timely filing follows those contracts.

Coding standardsClaims must meet CPT, ICD-10-CM and HCPCS Level II coding standards as applicable to support timely filing and adjudication.

Check the Prior Authorization Reference page for service-specific requirements.
Follow the plan's submission instructions and include all required clinical documentation.
Obtain and retain prior authorization approval numbers for claim submission.

Documentation Required

Claim submission and documentation

Submit complete claims within contractually determined timely filing limits. Coding must follow CPT, ICD-10-CM, and HCPCS standards. Neighborhood may request medical records for any billed service; documentation must support the services billed and the medical necessity of those services. Neighborhood follows CMS documentation standards when reviewing requested records.

Submit claims that are complete and compliant with contract timely filing guidelines.
Ensure coding aligns with CPT, ICD-10-CM, and HCPCS guidance.
Provide medical records promptly upon request to substantiate billed services and medical necessity.

Providers must document the additional work and the reason(s) for it (e.g., increased intensity, time, technical difficulty, patient severity, physical/mental effort).

Billing implicationCharge additional reimbursement only when documentation supports the substantially greater service as described.

Modifier 25

PurposeModifier 25 indicates a significant, separately identifiable Evaluation and Management (E/M) service performed by the same physician on the same day as another procedure or service.

Scope of useModifier 25 should be used only with E/M codes and should not be appended to the surgical procedure code(s).

Documentation expectationThe E/M service must be clearly documented as significant and separately identifiable from the other procedure performed the same day.

Modifier 59 and XE/XP/XS/XU

DefinitionModifier 59 identifies procedures/services (other than E/M) that are not normally reported together but are appropriate under the circumstances.

CMS subsetsUse specific X modifiers when more descriptive reporting is available: XE (separate encounter), XP (separate practitioner), XS (separate structure), XU (unusual non-overlapping service).

Use guidanceOnly use Modifier 59 when no more descriptive modifier exists and when it best explains the circumstances that make the procedures distinct.

Exclusions

Reference policyNon-covered modifiers are addressed in Neighborhood's Non-Covered Services Payment Policy; refer to that policy for modifiers excluded from coverage.

ScopeThis modifiers policy is limited to modifiers that affect claims processing and/or reimbursement; non-covered items live in the referenced policy.

Documentation requirements

Documentation standardNeighborhood follows CMS standards for proper medical documentation and may request medical records to support billed services and medical necessity.

Right to request recordsNeighborhood reserves the right to request medical records for any service billed to verify services and medical necessity.

Medical record contentDocumentation in the medical record must support the service(s) billed as well as the medical necessity of the service(s).