EXHIBIT A: AMERIGROUP REIMBURSEMENT MODIFIERS LISTING*
Refer to individual reimbursement policies for specific modifier requirements, guidelines and
exemptions.
Modifier
Description
Standard effect on reimbursement
22
Increased procedural service
Increase to 120 percent of rate
24
Unrelated evaluation and management
service by same physician during
postoperative period
Allows service to be reimbursed at
100 percent of rate
25
Significant, separately identifiable
evaluation and management service by
same physician on same day of procedure
or other service
*also for facility use
Allows service to be reimbursed at
100 percent of rate
26
Professional component
Fee schedule
50
Bilateral procedure
*also for facility use
Increase to 150 percent of rate

Medicaid based: 100 percent of
primary procedure, 50 percent
of secondary, 25 percent of
third and additional procedures
Medicare based: 100 percent of
primary procedure, 50 percent
of secondary and additional
procedures
51
Multiple procedure
52
Reduced service
*also for facility use
Reduction to 50 percent of rate
53
Discontinued service
Reduction to 50 percent of rate
54
Surgical care only
Reduction to 70 percent of rate
55
Postoperative care only
Reduction to 20 percent of rate
56
Preoperative care only
Reduction to 10 percent of rate
57
Decision for surgery
Allows service to be reimbursed at
100 percent of rate
59
Distinct procedural service
*also for facility use
Allows service to be reimbursed at
100 percent of rate
62
Co-surgeons
62.5 percent of rate to each
surgeon
63
Procedure performed on infants less than
4 kg
Increase to 125 percent of rate
PEC-ALL-0326-11
EXHIBIT A_Modifier Usage

April 2011
1
66
Surgical Teams
Allows service to be reimbursed at
100 percent of rate to each surgeon
73
Discontinued outpatient hospital/
Ambulatory Surgery Center (ASC)
procedure prior to administration of
anesthesia
*for facility use only
Reduction to 50 percent of rate
74
Discontinued outpatient hospital/
Ambulatory Surgery Center (ASC)
procedure after administration of
anesthesia
*for facility use only
Allows service to be reimbursed at
100 percent of rate
76
Repeat procedure by the same physician
*also for facility use
Allows service to be reimbursed at
100 percent of rate
77
Repeat procedure by another physician
*also for facility use
Allows service to be reimbursed at
100 percent of rate
78
Unplanned return to operating/procedure
room by same physician following initial
procedure for a related procedure during
postoperative period
*also for facility use
Reduction to 70 percent of rate
80
Assistant at surgery
Reduction to 16 percent of rate
81
Minimal assistant at surgery
Reduction to 16 percent of rate
82
Assistant at surgery (when a qualified
resident surgeon is not available)
Reduction to 16 percent of rate
91
Repeat a laboratory test
*also for facility use
Allows service to be reimbursed at
100 percent of rate
AA
Anesthesiology service performed
personally by an anesthesiologist
Allows service to be reimbursed at
100 percent of rate
AD
Medical supervision by a physician; more
than four concurrent anesthesia
procedures
Allows up to three relative value
units per procedure
AH
Clinical psychologist
Allows diagnostic services to be
reimbursed at 100 percent of rate;
reduction to 62.5 percent of rate
for all other services
AJ
Clinical social worker
Reduction to 75 percent of rate
AQ
Physician providing a service in an unlisted
Health Professional Shortage Area (HPSA)
Increase to 110 percent of rate
PEC-ALL-0326-11
EXHIBIT A_Modifier Usage
April 2011
2
Physician Assistant (PA), Nurse
Practitioner (NP) or Clinical Nurse
Specialist (CNS) services for assistant at
surgery
Reduction to 10.4 percent of rate
Transportation origin and destination
Allows service to be reimbursed at
100 percent of rate
FC
Partial credit received on replaced device
Reduction to 50 percent of rate
GF
Physician services provided by a
nonphysician in a critical access hospital;
nonphysician: NP, Certified Registered
Nurse Anesthetist (CRNA), Certified
Registered Nurse (CRN), CNS or PA
Reduction to 85 percent of rate
GM
Multiple transports
Reduction to 50 percent of rate
GT
Telemedicine via interactive audio and
video telecommunications systems
Allows service to be reimbursed at
100 percent of rate
HM
Less than Bachelor’s degree level
Negotiated percentage of rate; not
payable under Medicare
HN
Bachelor’s degree level
Negotiated percentage of rate; not
covered under Medicare
HO
Master’s degree level
Negotiated percentage of rate
HP
Doctoral level
Allows service to be reimbursed at
100 percent of rate
HQ
Group setting (for behavioral health use)
Fee schedule
HT
Multidisciplinary team (for behavioral
health use)
Fee schedule
KR
Rental item, durable medical equipment –
billing for partial month
Reduction to 50 percent of rate for
equipment
NU
New equipment
Allows equipment to be reimbursed
at 100 percent of rate
Anesthesia physical status
Amerigroup does not allow
additional reimbursement
QK
Medical direction of two, three or four
concurrent anesthesia procedures
involving qualified individuals
Reduction to 50 percent of rate
QL
Member pronounced dead, after
ambulance called but before loaded
onboard ambulance
Allows reimbursement of base rate
only at 100 percent
QX
CRNA service with medical direction by a
physician
Reduction to 50 percent of rate
PEC-ALL-0326-11
EXHIBIT A_Modifier Usage
AS
D/E/G/H/I/J/
N/P/R/S/X
P1/P2/P3/
P4/P5/P6
April 2011
3
QY
Anesthesiologist medically directs one
CRNA
Reduction to 50 percent of rate
QZ
CRNA service without medical direction by
a physician
Allows service to be reimbursed at
100 percent of rate
RR
Rental equipment
Reduction to a percentage of the
purchase price per the rental terms
SB
NP (for use by midwives only)
Reduction to 65 percent of
physician rate
SH
Second concurrently administered infusion
therapy
Reduction to 50 percent of rate
SJ
Third or more concurrently administered
infusion therapy
Reduction to 25 percent of rate
TC
Technical component
Fee schedule
TD
Registered Nurse (RN) (for behavioral
health use)
Fee schedule
TE
Licensed Practical Nurse (LPN) (for
behavioral health use)
Fee schedule
TK
Extra member or passenger,
nonambulance transportation
Reduction to 50 percent of rate
UE
Used equipment
Allows equipment to be reimbursed
at 100 percent of rate
UN
Portable/mobile radiology transport – two
members served
Reduction to 50 percent of rate
UP
Portable/mobile radiology transport –
three members served
Reduction to 33 percent of rate
UQ
Portable/mobile radiology transport – four
members served
Reduction to 25 percent of rate
UR
Portable/mobile radiology transport – five
members served
Reduction to 20 percent of rate
US
Portable/mobile radiology transport – six
or more members served
Reduction to 16 percent of rate
* List does not include state-specific modifiers. All modifiers are for use by professional
providers only unless otherwise indicated in modifier description.
PEC-ALL-0326-11
EXHIBIT A_Modifier Usage
April 2011
4