Currentpriority healthPolicy BILLING POLICY No. 055

FACILITY MODIFIERS

Defines facility-level billing modifiers, their meanings, usage, and documentation requirements for claim submission; applies to Priority Health commercial, Medicare (per CMS), and Medicaid (per MDHHS) products.

Policy Summary

Payerpriority health

PolicyFACILITY MODIFIERS

Policy CodePolicy BILLING POLICY No. 055

Change TypeNon-material edits (layout and sections added/removed)

Effective Date

Next Review Date

Key ActionBill facility modifiers on a UB-04 and include required documentation when submitting modifier AS.

SourceLink

POLICY UPDATE CHANGES

Added 'Disclaimer' section.

Added 'Related denial language' section.

Updated 'Applies to' section.

Removed 'Place of Service' section.

13listed facility modifiers

3most recent review dates listed

3applies to payer product categories

Application and Modifier Use

General application and billing guidance

Applies to product lines; billing policies define claim submission and reimbursement/coding requirements but do not guarantee payment — authorizations and medical necessity are still required.

ALL of the following

Applies to
- Commercial
- Medicare follows CMS unless otherwise specified
- Medicaid follows MDHHS unless otherwise specified
Billing policies outline guidelines to assist providers in accurate claim submissions and define reimbursement or coding requirements if the service is covered by a Priority Health member's benefit plan; they do not guarantee payment.
Authorizations and medical necessity requirements appropriate to procedure, diagnosis and frequency are still required; an authorization is not a guarantee of payment.
Proper billing and submission guidelines must be followed, including use of industry-standard CPT, HCPCS and revenue codes, and complete medical record documentation to the highest level of specificity; failure to document will result in denial or recoupment actions.

Modifier 53 — Discontinued Procedure

Usage guidance for modifier 53.

ALL of the following

Modifier 53 may be reported when a surgical or diagnostic procedure was started but was discontinued due to extenuating circumstances or those that threaten the wellbeing of the patient.
Do not use modifier 53 to report elective cancellation of a procedure prior to anesthesia induction and/or surgical preparation in the operating suite; for outpatient hospital/ASC reporting of a previously scheduled procedure that is partially reduced or cancelled prior to or after administration of anesthesia, see modifiers 73 and 74.

Modifiers GT and GX

Telehealth and liability notice modifiers.

ANY of the following

Modifier GT: Used to indicate telehealth services; except for demonstrations in Alaska and Hawaii, all telehealth must be interactive.
Modifier GX: Use to provide beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute; must be used with non-covered charges only.

Facility Modifiers and Units

Facility ModifiersModifier

53	Discontinued Procedure
AS	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CG	Policy criteria applied
EA	Erythropoietic stimulating agent (ESA) administered to treat anemia due to anticancer chemotherapy
EB	Erythropoietic stimulating agent (ESA) administered to treat anemia due to anticancer radiotherapy
EC	Erythropoietic stimulating agent (ESA) administered to treat anemia not due to anticancer radiotherapy or anticancer chemotherapy
ED	Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 G/dl) for three or more consecutive billing cycles immediately prior to and including the current cycle
EE	Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 G/dl) for three or more consecutive billing cycles immediately prior to and including the current cycle
GT	Via interactive audio and video telecommunication systems
GX	Notice of liability issued, voluntary under payer policy

1–10 of 15

1/2

Units for bilateral procedure

ThresholdUnits > 1 for bilateral procedure requires modifier 50 (related denial x82)

Related denial codex82 — referenced when units >1 for bilateral procedure without modifier 50

Action for billingAppend modifier 50 when reporting more than one unit for a bilateral procedure to avoid denial x82

Billing Requirements and Required Documentation

Documentation Required

AS documentation requirement

Append the AS modifier to appropriate procedure codes when non-physician practitioners (NPPs) (CNS, NP, PA) assist as an assistant surgeon and provide more than ancillary services. This modifier may only be submitted with surgery codes. Additional documentation is required in the medical record: 1) a statement that no qualified resident was available to perform the service, or 2) a statement indicating that exceptional medical circumstances exist, or 3) a statement indicating the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients.

Append AS only with surgery CPT codes
Include one of the three required statements in the medical record

Billing Rule

UB-04 billing requirement

Facility modifiers (including GX) are billed on a UB-04 only. Include the appropriate facility modifier with the claim as required.

Facility modifiers are UB-04 only
Examples: 53, AS, CG, EA, EB, EC, ED, EE, GT, GX, JA, JB, V5, V6, V7

Documentation Required

GX usage for liability notice

Use modifier GX to provide beneficiaries with a voluntary notice of liability for services excluded from Medicare coverage by statute. GX must be used only with non-covered charges.

Apply GX only for non-covered services where voluntary liability notice is appropriate
GX is a facility modifier billed on the UB-04 (see facility modifier list)

Key Terms

Modifier

DefinitionModifiers indicate a service or procedure was altered by specific circumstances without changing the procedure definition or code; they add specificity and are two digits.

Example modifier (discontinued)53 — Discontinued Procedure

Facility modifier billingFacility modifiers are billed on a UB-04 only.

Facility modifier billing

Billing formFacility modifiers are billed on a UB-04 only.

Common facility modifiersExamples include 53 (Discontinued Procedure), AS (Assistant at surgery), GT (telehealth), GX (notice of liability).

ScopeApplies to facility-level billing and coding; use UB-04 for submission of these modifiers.