R 418.101004 Modifier code reimbursement.

Rule 1004. (1) Modifiers may be used to report that the service or procedure performed was altered by a specific circumstance but does not change the definition of the code. This rule lists procedures for reimbursement when certain modifiers are used. A complete listing of modifiers is listed in Appendix A of "Current Procedural Terminology CPT® 2025 Professional Edition,” and the "HCPCS 2025 Level II Professional Edition" as adopted by reference in R 418.10107. (2) When modifier code -25 is added to an evaluation and management procedure code, reimbursement must only be made when the documentation provided supports that the patient's condition required a significant separately identifiable evaluation and management service, other than the other service provided or beyond the usual preoperative and postoperative care. (3) When modifier code -26, professional component, is used with a procedure, the professional component must be paid. (4) If a surgeon uses modifier code -47 when performing a surgical procedure, anesthesia services that were provided by the surgeon and the maximum allowable payment for the anesthesia portion of the service is calculated by multiplying the base unit of the appropriate anesthesia code by $42.00. No additional payment is allowed for time units. (5) When modifier code -50 or -51 is used with surgical procedure codes, the services must be paid according to the following, as applicable: (a) The primary procedure at not more than 100% of the maximum allowable payment or the billed charge, whichever is less. (b) The secondary procedure and the remaining procedure or procedures at not more than 50% of the maximum allowable payment or the billed charge, whichever is less. (c) When multiple injuries occur in different areas of the body, the first surgical procedure in each part of the body must be reimbursed 100% of the maximum allowable payment or billed charge, whichever is less, and the second and remaining surgical procedure or procedures must be identified by modifier code -51 and be reimbursed at 50% of the maximum allowable payment or billed charges, whichever is less. (d) When modifier -50 or -51 is used with a surgical procedure with a maximum allowable payment of by report, the maximum allowable payment must be 50% of the provider's usual and customary charge or 50% of the reasonable amount, whichever is less. (6) The multiple procedure payment reduction must be applied to the technical and professional component for more than 1 radiological imaging procedure furnished to the same patient, on the same day, in the same session, by the same physician or group practice. When modifier -51 is used with specified diagnostic radiological imaging procedures, the payment for the technical component of the procedure must be reduced by 50% of the maximum allowable payment and payment for the professional component of the procedure must be reduced to 75% of the maximum allowable payment. A table of the diagnostic imaging CPT® procedure codes subject to the multiple procedure payment reduction are provided by the agency in a manual separate from these rules. (7) When modifier code -TC, technical services, is used to identify the technical component of a radiology procedure, payment must be made for the technical component only. The maximum allowable payment for the technical portion of the radiology procedure is designated on the agency’s website, www.michigan.gov/leo/bureaus-agencies/wdca. (8) When modifier -57, initial decision to perform surgery, is added to an evaluation and management procedure code, the modifier -57 indicates an evaluation and management service resulted in the initial decision to perform surgery, either the day before or the day of a major surgery, and is not part of the global surgical service. (9) When both surgeons use modifier -62 and the procedure has a maximum allowable payment, the maximum allowable payment for the procedure must be multiplied by 25%. Each surgeon is paid 50% of the maximum allowable payment multiplied by 25%, or 62.5% of the maximum allowable payment. If the maximum allowable payment for the procedure is by report, the reasonable amount must be multiplied by 25% and be divided equally between the surgeons. (10) When modifier code -80 is used with a procedure, the maximum allowable payment for the procedure must be 20% of the maximum allowable payment listed in these rules, or the billed charge, whichever is less. If a maximum payment has not been established and the procedure is by report, payment must be 20% of the reasonable payment amount paid for the primary procedure. (11) When modifier code -81 is used with a procedure code that has a maximum allowable payment, the maximum allowable payment for the procedure must be 13% of the maximum allowable payment listed in these rules or the billed charge, whichever is less. If modifier code -81 is used with a by report procedure, the maximum allowable payment for the procedure must be 13% of the reasonable amount paid for the primary procedure. (12) When modifier -82 is used and the assistant surgeon is a licensed doctor of medicine, doctor of osteopathic medicine and surgery, doctor of podiatric medicine, or a doctor of dental surgery, the maximum level of reimbursement is the same as modifier -80. If the assistant surgeon is a physician's assistant, the maximum level of reimbursement is the same as modifier -81. If an individual other than a physician or a certified physician's assistant bills using modifier -82, the charge and payment for the service is reflected in the facility fee. (13) When modifier -GF is billed with evaluation and management or minor surgical services, the carrier shall reimburse the procedure at 85% of the maximum allowable payment, or the usual and customary charge, whichever is less. (14) When modifier -95 is used with procedure code 97161 to 97168, or those listed in Appendix P of the CPT® codebook, as adopted by reference in R 418.10107, excluding CPT® codes 99242 to 99245 and 99252 to 99255, the telemedicine services are reimbursed according to all of the following: (a) The carrier shall reimburse the procedure code at the non-facility maximum allowable payment, or the billed charge, whichever is less. (b) Supplies and costs for the telemedicine data collection, storage, or transmission must not be unbundled and reimbursed separately. (c) Originating site facility fees must not be separately reimbursed. (15) Modifier -CO must be appended to a procedure code if the procedure was furnished entirely by the occupational therapy assistant (OTA), or if the OTA has provided a portion of a procedure, separately from the part that is furnished by the occupational therapist, exceeding 10% of the total time for the procedure code. When modifier -CO is used, the procedure code must be reimbursed at 85% of the maximum allowable payment, or the usual and customary charge, whichever is less. Modifier -CO and the corresponding 15% reduction is not applicable if the occupational therapist has provided more than half of the timed procedure code without the minutes provided by the OTA. (16) Modifier -CQ must be appended to a procedure if the procedure was furnished entirely by the physical therapy assistant (PTA), or if the PTA has provided a portion of a procedure, separately from the part that is furnished by the physical therapist, exceeding 10% of the total time for the procedure code. When modifier -CQ is used, the procedure code must be reimbursed at 85% of the maximum allowable payment, or the usual and customary charge, whichever is less. Modifier -CQ and the corresponding 15% reduction is not applicable if the physical therapist has provided more than half of the timed procedure code without the minutes provided by the PTA.