2022 Modifier Table for All Products

The following table lists all modifiers on the HealthPartners standard modifier table that affect
payment on Medicare, Medicaid and commercial claims by either increasing or decreasing the
allowable amount. HealthPartners follows the CMS modifier increases or decreases or the
industry standards for various modifiers. Beginning January 1, 2022, HealthPartners will be
able to increase or decrease up to four modifiers on each claim line. Some modifiers are
addressed in separate policies, so please review the specific policy for additional information on
the identified modifiers below.

Modifier Modifier Description Percent of Allowable

22 Increased procedural services 110%

Significant, separately identifiable evaluation and

25 management service by the same physician on the same day of 100/50/0/0
the procedure or other service
See Bilateral Billing
50 Bilateral procedure
Guidelines Policy
See Multiple Surgeries
51 Multiple Surgeries
Billing Guideline Policy

52 Reduced services 50%

53 Discontinued Procedure 50%

54 Surgical care only Varies per MPPR Policy

55 Postoperative management only Varies per MPPR Policy

56 Preoperative management only Varies per MPPR Policy

62 Two surgeons Varies per MPPR Policy

66 Three or more surgeons 62.50%

78 Unplanned return to operating or procedure room Varies per MPPR Policy

See Assistant Surgeon
80 Assistant surgeon
Services Policy
See Assistant Surgeon
81 Minimum assistant surgeon
Services Policy
Assistant surgeon (when qualified resident surgeon not See Assistant Surgeon
82
available) Services Policy

Physician assistant, nurse practitioner, or clinical nurse See Assistant Surgeon

AS
specialist services for assistant at surgery Services Policy

CO Outpatient occupational therapy services 85%

CQ Outpatient physical therapy services 85%

CT Computed Tomography Services Furnished 85%

Item provided without cost to provider, supplier or

practitioner, or full credit received for replaced device
FB 0%
(examples, but not limited to, covered under warranty,
replaced due to defect, free samples)

FC Partial credit received for replaced device 100%

FX X-Ray Taken Using Film 80%

FY Computer Radiography X-Ray 93%

Item or service expected to be denied as not reasonable or

GZ 0%
necessary

PA Surgical or other invasive procedure on wrong body part See Never Events Policy

PB Surgical or other invasive procedure on wrong patient See Never Events Policy

PC Wrong surgery or other invasive procedure on patient See Never Events Policy

PM Post Mortem 100%

Second Concurrently Administered Infusion Therapy

SH 50%
(non transportation codes)

Third or more Concurrently Adminstered Infusion Therapy

SJ 50%
(non transportation codes)

XE Separate encounter 100%

XS Separate structure 100%

XP Separate practitioner 100%

XU Unusual non-overlapping services 100%