modif app

Modifiers: Approved List 1

Below is a list of approved modifier codes for use in billing Medi-Cal. Modifiers not listed in this section
are unacceptable for billing Medi-Cal.

Modifier Overview Some modifier information in this section is taken from the CPT code
book (Current Procedural Terminology code book) and HCPCS code
book (Healthcare Common Procedure Coding System, Level II).

Discontinued Modifiers Medicaid programs have traditionally tailored modifiers for their state’s
needs. These interim (or local) modifiers are being phased out under
HIPAA requirements. Refer to the list of discontinued and invalid
modifiers at the end of this section.

National Correct Medi-Cal claims are subject to a set of claims processing edits that
Coding Initiative are federally mandated. The edits, controlled by the Centers for
Medicare & Medicaid Services (CMS), are part of the National Correct
Coding Initiative (NCCI).

Modifiers relevant to the NCCI edit methodology are designated

“NCCI associated” in the following modifier list. See the Correct
Coding Initiative: National section for how NCCI affects
reimbursement.

Note: NCCI does not allow more than one NCCI-associated modifier
on a line for Treatment Authorization Requests (TARs),
CMS-1500 claims and UB-04 claims. TARs and claims
containing two or more NCCI-associated modifiers on
the same line will be denied. In addition, placement of
modifiers on the claim is important. An NCCI-associated
modifier should not appear in the first modifier position
(next to the procedure code) unless it is the only modifier on
that claim line.

2 – Modifiers: Approved List

June 2011
modif app
2
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
22* Increased procedural services May be used with computed tomography
(CT) codes when additional slices are
required or a more detailed evaluation is
necessary.
Used by Local Educational Agency (LEA)
to denote an additional 15-minute service
increment rendered beyond the required
initial service time. See Local Educational
Agency (LEA) in the appropriate Part 2
manual for more information.
Surgical: May be billed when procedures
involve significantly increased operative
complexity and/or time in a significantly
altered surgical field resulting from the
effects of prior surgery, marked scarring,
adhesions, inflammation, or distorted
anatomy, irradiation, infection, very low
weight (for example, neonates and small
infants less than 10 kg) and/or trauma (as
documented in a recipient’s medical
record). Justification is required on the
claim.
Anesthesia: Prone position, base units
less than or equal to three units.
24* Unrelated E&M service by the
same physician or other
NCCI
qualified health care
associated
professional during a
postoperative period
25* Significant, separately identifiable
E&M service by the same
NCCI
physician or other qualified
associated
health care professional on the
same day of the procedure or
other service
26* Professional component

* Check the CPT Book for Guidelines in using this modifier

2 – Modifiers: Approved List

March 2019
 modif app
3
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
27* Increased procedural services
NCCI
associated
33* Preventive service Claims billed using modifier 33 are not
subject to specific ICD-10-CM inclusion
and/or exclusion criteria. Use of modifier 33
indicates the service was provided in
accordance with a U.S. Preventive Services
Task Force A or B recommendation.
47* Anesthesia by surgeon Do not use as a modifier for anesthesia
codes.
50* Bilateral procedure

51* Multiple procedures

52* Reduced services Surgical: For use with surgery codes

66820 – 66821, 66830, 66840, 66850, 66920,
66930, 66940 and 66982 – 66985. Requires
“By Report” documentation.
Used by LEA to denote an annual re-
assessment. See Local Educational Agency
(LEA) in the appropriate Part 2 manual for
more information. LEA does not require “By
Report” documentation.
53* Discontinued procedure Requires “By Report” documentation.
54* Surgical care only
55* Postoperative management only
57 † Decision for surgery (major surgery
only, day before or day of
procedure)
58* Staged or related procedure or May be used with codes 15002 – 15429 and
service by the same physician 52601 to address subsequent part(s) of a
NCCI
during the postoperative period staged procedure.
associated

* Check the CPT Book for Guidelines in using this modifier

† NCCI associated

2 – Modifiers: Approved List

March 2019
modif app
4
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
59* Distinct procedural service Used primarily with codes 36818 – 36819
and 76816. Also used with other codes,
NCCI
as appropriate, for NCCI purposes.
associated
62* Two surgeons
66* Surgical team
73 Discontinued outpatient To be reported by hospital outpatient
hospital/ambulatory surgery department or surgical clinic only.
center (ASC) procedure prior to Requires “By Report” documentation.
the administration of anesthesia
(to be reported by hospital
outpatient department or surgical
clinic, only)
74 Discontinued outpatient To be reported by hospital outpatient
hospital/ambulatory surgery department or surgical clinic only.
center (ASC) procedure after Requires “By Report” documentation.
administration of anesthesia
76* Repeat procedure or service by
same physician
77* Repeat procedure by another
physician
78* Unplanned return to the
operating/procedure room by the
NCCI
same physician following initial
associated
procedure for a related procedure
during the postoperative period

* Check the CPT book for guidelines in using this modifier.

2 – Modifiers: Approved List

March 2011
 modif app
5
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
79* Unrelated procedure or service by
the same physician during the
NCCI
postoperative period
associated
80* Assistant surgeon
90* Reference (outside) laboratory Only specified providers may use this
modifier.
91* Repeat clinical diagnostic
laboratory test
NCCI
associated
95 Synchronous telemedicine
service rendered via a real-time
interactive audio and video
telecommunications system
99* Multiple modifiers Used when two or more modifiers are
necessary to completely delineate a
service; the multiple modifiers used must
be explained in the Remarks field
(Box 80)/Additional Claim Information field
(Box 19) of the claim.
Do not bill 99 when billing split-billable
claims without a modifier (professional and
technical service component) or with
modifier 26 (professional component) and
TC (technical component). The claim will
be denied.
Also used in special circumstances as
specified by the Department of Health
Care Services (DHCS). For an example,
refer to the Surgery Billing Examples:
UB-04 or Surgery Billing Examples:
CMS-1500 sections in the appropriate
Part 2 manual.

* Check the CPT book for guidelines in using this modifier.

2 – Modifiers: Approved List

June 2017
modif app
6
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
AA Anesthesia performed by an
anesthesiologist
AG Primary physician Surgical: Used to denote a primary
surgeon. In the case of multiple primary
surgeons, two or more surgeons can use
modifier AG for the same patient on the
same date of service if the procedures are
performed independently and in different
specialty areas.
This does not include surgical teams or
surgeons performing a single procedure
requiring different skills. An explanation of
the clinical situation and operative reports
by all surgeons involved must be included
with the claim.
Used by LEA to denote licensed
physicians/psychiatrists. See Local
Educational Agency (LEA) in the
appropriate Part 2 manual for more
information.
AH Clinical psychologist Used by LEA to denote licensed
psychologists, licensed educational
psychologists and credentialed school
psychologists. See Local Educational
Agency (LEA) in the appropriate Part 2
manual for more information.
AI Principal physician of record Allowable for all procedure codes.
AJ Clinical social worker Used by LEA to denote licensed clinical
social workers and credentialed school
social workers. See Local Educational
Agency (LEA) in the appropriate Part 2
manual for more information.

2 – Modifiers: Approved List

April 2017
 modif app
7
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
AP Determination of refractive state Use only for ophthalmology.
was not performed in the course
of diagnostic ophthalmological
examination
AS Physician assistant, nurse Certified nurse midwives (CNM) may be
practitioner, or clinical nurse reimbursed as an “assistant at surgery”
specialist services for assistant during cesarean section deliveries
at surgery performed by a licensed physician and
surgeon.
AY Item or service furnished to an
ESRD patient that is not for the
treatment of ESRD
AZ Physician providing a service in a
dental health profession shortage
area for the purpose of an
electronic health record incentive
payment
CS Item of service related, in whole
or in part, to an illness, injury, or
condition that was caused by or
exacerbated by the effects, direct
or indirect, of the 2010 oil spill in
the Gulf of Mexico, including but
not limited to subsequent clean-
up activities
DA Oral health assessment by a
licensed health professional other
than a dentist
DS Ambulance service origin code D Medical transport dry run.
(diagnostic or therapeutic site
other than P or H when these are
used as origin codes) with When billed with modifier QN, modifier DS
ambulance service destination must be in the first modifier position.
code S (scene of accident or
acute event)

2 – Modifiers: Approved List

April 2017
modif app
8
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
E1 Upper left, eyelid Use modifier SC with CPT code 68761
NCCI (closure of lacrimal punctum; by
associated thermocauterization, ligation, or laser
surgery; by plug, each) to indicate use of
temporary collagen punctal plugs.
Modifiers E1 thru E4 are used in
connection with permanent silicone punctal
plugs and procedures on the eyelids.
E2 Lower left, eyelid Same as above
NCCI
associated
E3 Upper right, eyelid Same as above
NCCI
associated
E4 Lower right, eyelid Same as above
NCCI
associated
EP Service provided as part of a
Medicaid early and periodic
screening diagnostic and
treatment (EPSDT).
ET Emergency services
F1 Left hand, second digit
NCCI
associated
F2 Left hand, third digit
NCCI
associated
F3 Left hand, fourth digit
NCCI
associated
F4 Left hand, fifth digit
NCCI
associated
F5 Right hand, thumb
NCCI
associated
F6 Right hand, second digit
NCCI
associated
F7 Right hand, third digit
NCCI
associated

2 – Modifiers: Approved List

August 2018
 modif app
9
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
F8 Right hand, fourth digit
NCCI
associated
F9 Right hand, fifth digit
NCCI
associated
FA Left hand, thumb
NCCI
associated
FP Family planning services Add modifier to HCPCS and CPT codes as
appropriate:

Z1032 – Z1038 + FP
Z6200 – Z6500 + FP
59400 + FP
59510 + FP
59610 + FP
59618 + FP
99201 – 99215 + FP
99241 – 99245 + FP
99281 – 99285 + FP
99341 – 99353 + FP
99384 + FP
99394 + FP
GC Physician services provided by a Add modifier to CPT codes 99201 – 99499
resident and teaching physician (Evaluation and Management Services) as
appropriate.
GN Service delivered under an Used by LEA to denote licensed
outpatient speech-language speech-language pathologists and
pathology plan of care speech-language pathologists. See Local
Educational Agency (LEA) in the
appropriate Part 2 manual for more
information.

2 – Modifiers: Approved List

April 2017
modif app
10
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations

GO Service delivered under an Used by LEA to denote registered

outpatient occupational therapy occupational therapists. See Local
plan of care Educational Agency (LEA) in the
appropriate Part 2 manual for more
information.

GP Service delivered under an Used by LEA to denote licensed physical

outpatient physical therapy plan therapists. See Local Educational Agency
of care (LEA) in the appropriate Part 2 manual for
more information.

GQ Via asynchronous Used to denote store-and-forward

telecommunications system telecommunications system.

GT Service rendered via interactive Used to denote real-time

audio and video telecommunications system.
telecommunications systems

GU Waiver of liability statement

issued as required by payer
policy, routine notice

GX Notice of liability issued, voluntary

under payer policy

GY Item or service statutorily Used to denote that the Early and Periodic
excluded; does not meet the Screening, Diagnostic and Treatment
definition of any Medicare benefit (EPSDT) recipient with full-scope Medi-Cal
or for non-Medicare insurers, is has started a physician-ordered course of
not a contract benefit treatment before reaching 21 years of age
and the recipient is to complete the course
of the prescribed treatment; OR the
recipient started a physician-ordered
course of treatment before July 1, 2009,
and required additional time to complete
treatment after this date. GY is to be used
ONLY for services exempted from the
optional benefits exclusion policy.
Use of GY only applies to medical/surgical
care required for the treatment and the
resolution of the acute episode.

2 – Modifiers: Approved List

July 2019
 modif app
11
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
HA Child/adolescent program Used by pediatric subacute facility to
denote that the patient is a child.
HB Adult program, nongeriatric Used by adult subacute facility to denote
that the patient is an adult.
HD Pregnant/parenting women’s Used when billing for either a positive or
program negative depression screening for pregnant
or postpartum recipients.
HM Less than bachelor degree level Used to denote that the rendering provider
is certified as a Sign Language Interpreter.
HN Ambulance service origin code H Ambulance modifier H may be used in
(hospital) with ambulance service conjunction with modifier N (H+N) to
destination code N (skilled indicate transportation from an acute care
nursing facility) hospital to a skilled nursing facility.
When billed with modifier QN, modifier HN
must be in the first modifier position.
HO Masters degree level Used by LEA to denote program
specialists. See Local Educational Agency
(LEA) in the appropriate Part 2 manual for
more information.
HT Multi-disciplinary team Used by California Community Transition
(CCT) Demonstration providers to denote
CCT services.
J4 DMEPOS item subject to Allowable but not required for all DME
DMEPOS competitive bidding codes.
program that is furnished by a
hospital upon discharge
KC Replacement of special power
wheelchair interface
KX Requirements specified in the Specific required documentation on file.
medical policy have been met
Used by Diabetes Prevention Program
(DPP) organizations to indicate DPP
services were rendered through video-
conferencing, online, distance learning
or other virtual tool.

2 – Modifiers: Approved List

June 2019
modif app
12
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
LC Left circumflex coronary artery
NCCI
associated
LD Left anterior descending coronary
artery
NCCI
associated
LM † Left main coronary artery

LT Left side (used to identify

procedures performed on the left
NCCI
side of the body)
associated
NB Nebulizer system, any type,
FDA-cleared for use with specific
drug
NU New equipment Used to denote purchase of new
equipment.
P1* A normal, healthy patient Used to denote anesthesia services
provided to a normal, uncomplicated
patient.
P3* A patient with severe systemic Used to denote anesthesia services
disease provided to a patient with severe systemic
disease.
P4* A patient with severe systemic Used to denote anesthesia services
disease that is a constant threat provided to a patient with severe systemic
to life disease that is a constant threat to life.
P5* A moribund patient who is not Used to denote anesthesia services
expected to survive without the provided to a moribund patient who is not
operation expected to survive without the operation.

* Check the CPT Book for Guidelines in using this modifier

† NCCI associated

2 – Modifiers: Approved List

April 2017
 modif app
13
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
PA Surgery, wrong body part Allowable for all procedure codes.
PB Surgery, wrong patient Allowable for all procedure codes.
PC Wrong surgery on patient Allowable for all procedure codes.
PI Positron emission tomography Allowable but not required for all radiology
(PET) or PET/computed procedure codes.
tomography (CT) to inform initial
treatment strategy of tumors
PS PET or PET/CT to inform the Allowable but not required for all radiology
subsequent treatment strategy of procedure codes.
cancerous tumors
PT Colorectal cancer screening test;
converted to diagnostic test or
other procedure
QA Prescribed amounts of
stationary oxygen for daytime
use while at rest and nighttime
use differ and the average of
the two amounts is less than
one liter per minute (LPM)
QB Prescribed amounts of
stationary oxygen for daytime
use while at rest and nighttime
use differ and the average of
the two amounts exceeds four
LPM and portable oxygen is
prescribed
QE Prescribed amount of stationary
oxygen while at rest is less than
one LPM
QF Prescribed amount of stationary
oxygen while at rest exceeds
four LPM and portable oxygen is
prescribed
QG Prescribed amount of stationary Use this modifier if portable oxygen is NOT
oxygen while at rest is greater prescribed.
than four LPM
QR Prescribed amounts of Use this modifier if portable oxygen is
stationary oxygen for daytime NOT prescribed.
use while at rest and nighttime
use differ and the average of
the two amounts is greater than
four LPM

2 – Modifiers: Approved List

May 2018
modif app
14
Approved Program-Specific: Use of the Modifier
National Modifier Description
Modifier and Special Considerations
QK Medical direction of two, three or Note: Modifier QK will also be used when
four concurrent anesthesia billing for the supervision of one
procedures involving qualified anesthesia procedure.
individuals
QN Ambulance service furnished directly May be used in conjunction modifier HN
by a provider of services for medical transportation, which is the
combination of ambulance service origin
code H (hospital) and ambulance service
destination code N (skilled nursing facility).
QP Documentation is on file showing Used for lab codes where documentation
that the laboratory test(s) was is on file showing that the test was ordered
ordered individually or ordered as individually.
a CPT-recognized panel other
than automated profile codes
80002 – 80019, G0058, G0059
and G0060
QS Monitored anesthesia care Used by California Children’s Services
service (CCS) to denote monitored anesthesia
care.
QW CLIA waived test Used to indicate that the provider is
performing testing for the procedure with
the use of a specific test kit from
manufacturers identified by the Centers for
Medicare & Medicaid Services (CMS).
QX CRNA service: with medical
direction by a physician
QY Medical direction of one certified
registered nurse anesthetist (CRNA)
by an anesthesiologist
QZ CRNA service: without medical
direction by a physician
RA Replacement Used to indicate replacement vision care
frames and lenses.
RB Replacement as part of a repair Used to indicate replacement parts during
repair of Durable Medical Equipment
(DME), including parts of eyeglass frames.

2 – Modifiers: Approved List

April 2017
 modif app
15
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
RC Right coronary artery
NCCI
associated
RI † Ramus intermedius
RR Rental Used to indicate when DME is to be
rented.
RT Right side (used to identify
procedures performed on the right
NCCI
side of the body)
associated
SA Nurse practitioner rendering
service in collaboration with a
physician
SB Nurse midwife Used when Certified Nurse Midwife service
is billed by a physician, hospital outpatient
department or organized outpatient clinic
(not by CNM billing under his or her own
provider number).
SC Medically necessary service or
supply
SE State and/or federally funded
programs/services
SK Member of high-risk population
(use only with codes for
immunization)
SL State-supplied vaccine Used for Vaccines For Children (VFC)
program recipients through 18 years of
age.

* Check the CPT Book for Guidelines in using this modifier

† NCCI associated

2 – Modifiers: Approved List

April 2017
modif app
16
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
T1 Left foot, second digit
NCCI
associated
T2 Left foot, third digit
NCCI
associated
T3 Left foot, fourth digit
NCCI
associated
T4 Left foot, fifth digit
NCCI
associated
T5 Right foot, great toe
NCCI
associated
T6 Right foot, second digit
NCCI
associated
T7 Right foot, third digit
NCCI
associated
T8 Right foot, fourth digit
NCCI
associated
T9 Right foot, fifth digit
NCCI
associated

2 – Modifiers: Approved List

April 2017
 modif app
17
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
TA Left foot, great toe
NCCI
associated
TC Technical component
TD Registered nurse (RN)
TE Licensed practical nurse Used by LEA to denote licensed vocational
(LPN)/Licensed vocational nurse nurses. See Local Educational Agency
(LVN) (LEA) in the appropriate Part 2 manual for
more information.
Used by Pediatric Palliative Care Waiver
Program (PPCWP) to denote licensed
vocational nurses providing services to
children receiving palliative care services.
TG Complex/high tech level of care
TH Obstetrical treatment/services, Used to denote that the service rendered is
prenatal or postpartum ONLY for pregnancy-related services and
services for the treatment of other
conditions that might complicate the
pregnancy. Modifier TH can be used for
up to 60 days after termination of
pregnancy. TH is to be used ONLY for
services exempted from the optional
benefits exclusion policy.
TL Early intervention/Individualized Used by LEA to denote that service is part
Family Services Plan (IFSP) of IFSP. See Local Educational Agency
(LEA) in the appropriate Part 2 manual for
more information.
TM Individualized Education Plan Used by LEA to denote that service is part
(IEP) of individualized education plan. See
Local Educational Agency (LEA) in the
appropriate Part 2 manual for more
information.

2 – Modifiers: Approved List

May 2019
modif app
18
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
TS Follow-up service Used by LEA to denote an amended
re-assessment. See Local Educational
Agency (LEA) in the appropriate Part 2
manual for more information.
TT Individualized service provided to Used by Home and Community-Based
more than one patient in same Services (HCBS) Waiver Program to
setting denote services provided to two HCBS
Nursing Facility/Acute Hospital (NF/AH)
Waiver recipients who reside in the same
residence. Also referred to as shared
services.
TU Special payment rate, overtime, Used by medical transportation to bill for
(air ambulance transportation waiting time in excess of the first
only), (emergency or 15 minutes, in one-half (1/2) hour
non-emergency) increments.
U1 Medicaid level of care 1, as Used by HCBS Waiver Program to denote
defined by each state skilled nursing services A or B level of
care.
Also used with HCPCS code A4269 to
indicate the type of spermicide (gel, jelly,
foam, cream). See the Family Planning
section in the appropriate Part 2 manual or
the Family PACT Policies, Procedures and
Billing Instructions (PPBI) manual for
details.
U2 Medicaid level of care 2, as Used by HCBS Waiver Program to denote
defined by each state skilled nursing services A or B level of
care. Also used with HCPCS code A4269
to indicate the type of spermicide
(suppository). See the Family Planning
section in the appropriate Part 2 manual or
the Family PACT PPBI manual for details.
U3 Medicaid level of care 3, as Used by HCBS Waiver Program to denote
defined by each state skilled nursing services A or B level of
care. Also used with HCPCS code A4269
to indicate the type of spermicide (vaginal
film). See the Family Planning section in
the appropriate Part 2 manual or the
Family PACT PPBI manual for details.
U4 Medicaid level of care 4, as Also used with HCPCS code A4269 to
defined by each state indicate the type of spermicide
(contraceptive sponge). See the Family
Planning section in the appropriate Part 2
manual or the Family PACT PPBI manual
for details.

2 – Modifiers: Approved List

April 2017
 modif app
19
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
U5 Medicaid level of care 5, as Used with HCPCS code J3490 to indicate
defined by each state emergency contraceptive pills (ulipristal
acetate). See the Family Planning section
in the appropriate Part 2 manual or the
Family PACT PPBI manual for details.
U6 Medicaid level of care 6, as Used by HCBS Waiver Program to
defined by each state separate California Community Transitions
(CCT) services from other waiver services.
Used with HCPCS code J3490 to indicate
emergency contraceptive pills
(levonorgestrel). See the Family Planning
section in the appropriate Part 2 manual or
the Family PACT PPBI manual for details.
Also used by Family PACT (Planning,
Access, Care and Treatment) Program
with HCPCS codes 99401, 99402 and
99403 to indicate Education and
Counseling (E&C) services. See the
Family PACT PPBI manual for details.
U7 Medicaid level of care 7, as Used to denote services rendered by
defined by each state Physician Assistant (PA).
U8 Medicaid level of care 8, as Used with HCPCS code J3490 to indicate
defined by each state medroxyprogesterone acetate for
contraceptive use.
U9 Medicaid level of care 9, as Used to denote services rendered by
defined by each state licensed midwife (LM).
UA Medicaid level of care 10, as Used for surgical or non-general
defined by each state anesthesia related supplies and drugs,
including surgical trays and plaster casting
supplies, provided in conjunction with a
surgical procedure code.
Also used to indicate outpatient heroin
detoxification services per visit, days 1 – 7.
See the Heroin Detoxification Billing Codes
section for details.
UB Medicaid level of care 11, as Used for surgical or general anesthesia
defined by each state related supplies and drugs, including
surgical trays and plaster casting supplies,
provided in conjunction with a surgical
procedure code.
Also used to indicate outpatient heroin
detoxification services per visit, days
8 – 21. See the Heroin Detoxification
Billing Codes section for details.

2 – Modifiers: Approved List

April 2017
modif app
20
Approved Program-Specific Use of the Modifier
National Modifier Description
Modifier and Special Considerations
UC Medicaid level of care 12, as Used to indicate outpatient heroin
defined by each state detoxification services once per week,
days 8 – 21 (in lieu of UB). See the Heroin
Detoxification Billing Codes section for
details.
UD Medicaid level of care 13, as Used by Section 340B providers to denote
defined by each state services provided or drugs purchased
under this program.
UJ Services provided at night Used by medical transportation to indicate
that services were provided between
7 p.m. and 7 a.m.
UN Two patients served Used to indicate that two patients were
served in medical transportation.
UP Three patients served Used to indicate that three patients were
served in medical transportation.
UQ Four patients served Used to indicate that four patients were
served in medical transportation.
UR Five patients served Used to indicate that five patients were
served in medical transportation.
US Six or more patients served Used to indicate that six or more patients
were served in medical transportation.
V5 Any vascular catheter (alone or Allowable for all procedure codes.
with any other vascular access)
V6 Arteriovenous graft (or other Allowable for all procedure codes.
vascular access not including a
vascular catheter)
V7 Arteriovenous fistula only (in use Allowable for all procedure codes.
with two needles)
XE Separate encounter: a service
that is distinct because it occurred
NCCI
during a separate encounter
Associated
XP Separate practitioner: a service
that is distinct because it was
NCCI
performed by a different
Associated
practitioner

2 – Modifiers: Approved List

April 2017
 modif app
21
Approved Program-Specific Use of the Modifier
Modifier National Modifier Description and Special Considerations
XS Separate structure: a service that
is distinct because it was
NCCI
performed on a separate
Associated
organ/structure
XU Unusual non-overlapping service:
the use of a service that is distinct
NCCI
because it does not overlap usual
Associated
components of the main service
YW Not applicable. This is an interim Required professional experience (applies
(local) modifier. only to speech therapists and audiologists).
ZL Not applicable. This is an interim This modifier is used to certify that initial
(local) modifier. comprehensive antepartum office visit
occurred within 16 weeks of the last
menstrual period (LMP) (up to and
including pregnancies of 16 weeks and
0/7ths days gestation only). Used with
HCPCS code Z1032 only. (Reimbursed
only once during pregnancy – service
limitation of once in nine months.)
Use of this modifier adds $56.63 to
reimbursement. Available only to
Comprehensive Perinatal Services
Program (CPSP) providers. For enrollment
information, see Pregnancy:
Comprehensive Perinatal Services
Program (CPSP) in the appropriate Part 2
manual.

2 – Modifiers: Approved List

September 2018
modif app
22
Discontinued and Invalid Modifiers

Below is a list of discontinued and invalid modifier codes for use in billing Medi-Cal. Modifiers listed below
are no longer acceptable for billing Medi-Cal.

Discontinued/ Discontinuation
Modifier Description
Invalid Modifier Date
21 September 1, 2009 Prolonged evaluation and management services (see
Evaluation and Management [E&M] section in the
appropriate provider manual on how to bill for prolonged
E&M visits).
60 May 1, 2009 Altered surgical field. Use modifier 22.
75 May 1, 2009 Concurrent care, services rendered by more than
one physician.
AF August 1, 2005 Anesthesia complicated by total body hypothermia
above 30 degrees.
AN February 1, 2009 Physician assistant service. Replaced by HIPAA
compliant modifier U7.
V8 October 1, 2012 Infection present. Allowable for all procedure codes.
V9 October 1, 2012 No infection present. Allowable for all procedure codes.

2 – Modifiers: Approved List

September 2018
 modif app
23
Discontinued/ Discontinuation
Modifier Description
Invalid Modifier Date
Y1 November 1, 2005 Rental without sales tax (hearing aids).
Y2 November 1, 2005 Purchase or repair without sales tax (hearing aids).
Y6 November 1, 2005 Rental with sales tax (hearing aids).
Y7 November 1, 2005 Purchase, repair, mileage with sales tax (standard item,
hearing aids).
YQ November 1, 2005 Certified Nurse Midwife service (when billed by a
physician, organized outpatient clinic or hospital
outpatient department). Replaced by HIPAA compliant
modifier SB.
YR February 1, 2009 Certified Nurse Midwife service (multiple modifiers)
(when billed by a physician, organized outpatient clinic
or hospital outpatient department). Replaced by HIPAA
compliant modifier 99.
YS November 1, 2005 Nurse Practitioner service. Replaced by HIPAA
compliant modifier SA.
YT February 1, 2009 Nurse Practitioner service (multiple modifiers). Replaced
by HIPAA compliant modifier 99.
YU February 1, 2009 Physician Assistant service (multiple modifiers).
Replaced by HIPAA compliant modifier 99.
YV July 1, 2001 AIDS Waiver providers only. Administrative expenses
when billed by Computer Media Claims (CMC).

2 – Modifiers: Approved List

September 2018
modif app
24
Discontinued/ Discontinuation
Modifier Description
Invalid Modifier Date
Z1 Not applicable. This Additional air mileage in excess of 10 percent of
is an interim (local) standard airway mileage distances. Reason for
modifier. additional mileage flown must be documented on the
claim or on an attachment.
ZA March 1, 2011 Anesthesia procedures complicated by unusual
position or surgical field avoidance.
Note: This local modifier was discontinued March 1,
2011. Use of this local modifier will result in claim
denial.
ZB March 1, 2011 Anesthesia (emergency services, healthy patient).
Note: This local modifier was discontinued
March 1, 2011. Use of this local modifier will result in
claim denial.
ZC March 1, 2011 Anesthesia complicated by extracorporeal
circulation.
Note: This local modifier was discontinued
March 1, 2011. Use of this local modifier will result in
claim denial.
ZD March 1, 2011 Emergency anesthesia (systemic disease).
ZE March 1, 2011 Nurse anesthetist service; elective anesthesia:
normal, healthy patient.
ZF March 1, 2011 Anesthesia supervision.
ZG March 1, 2011 Multiple anesthesia modifiers.
ZH March 1, 2011 Nurse anesthetist service; anesthesia special
circumstances: unusual position/field avoidance.
ZI March 1, 2011 Nurse anesthetist service; anesthesia special
circumstances: total body hypothermia.
ZJ March 1, 2011 Nurse anesthetist service; emergency anesthesia:
normal, healthy patient.
ZK November 1, 2005 Primary Surgeon. Replaced by HIPAA compliant
modifier AG.
ZM November 1, 2010 Supplies and drugs for surgical procedures with other
than general anesthesia or no anesthesia. Replaced by
HIPAA compliant modifier UA.
ZN November 1, 2010 Supplies and drugs for surgical procedures with general
anesthesia. Replaced by HIPAA compliant modifier UB.
ZO March 1, 2011 Nurse anesthetist service; anesthesia special
circumstances: extracorporeal circulation.

2 – Modifiers: Approved List

September 2018