| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Physician | | 04/25/2024 | Covered and Noncovered Services : CodesTopic #564 Modifiers
ForwardHealth accepts all valid, nationally recognized modifiers on claims and forms. Some modifiers impact claims processing and reimbursement while others are informational. Providers should refer to CPT and HCPCS guidelines for modifier definitions as well as information on appropriately using nationally recognized modifiers when submitting claims and other forms to ForwardHealth.
ForwardHealth also requires providers to indicate ForwardHealth-specific modifiers on claims and forms as appropriate. The modifiers in the following table have been specifically defined by ForwardHealth for physician, E&M, and surgery services.
| Modifier |
Description |
Notes |
| 50 |
Bilateral procedure |
Use of modifier 50 is allowed for those procedures for which the concept is considered appropriate according to standard coding protocols and HCPCS or CPT definitions. The maximum allowable fee schedule identifies procedures for which this modifier is allowable. |
| AQ |
Physician providing a service in an unlisted HPSA (Note: While the AQ modifier is defined for physicians only, any Medicaid HPSA-eligible provider may use the modifier when appropriate.) |
Providers receive enhanced reimbursement when services are performed in a HPSA. |
| Q4 | Service for ordering/referring physician qualifies as a service exemption | Providers rendering advanced imaging services for an ordering provider who is exempt from PA requirements are required to include modifier Q4. |
| TH |
Obstetrical treatment/services, prenatal or postpartum |
If a provider renders three or fewer antepartum care visits, the provider is required to include modifier TH with the appropriate E&M service code (99202–99215, G2212, and/or 99341–99350) to indicate that the code is being used for obstetrical treatment/services. If the services are HPSA eligible, the provider should include the HPSA modifier AQ in addition to modifier TH. |
| TJ |
Program group, child and/or adolescent |
Providers are required to use modifier TJ with procedure codes 99202–99215, G2212, 99281–99285, and 99341–99350 for members 18 years of age and younger. Providers should not use the HPSA modifier AQ with modifier TJ. Providers should only include the HPSA modifier in situations where both of these modifiers apply. |
| U1 |
Nonelective Cesarean Section (locally defined for physicians) |
Providers may use modifier U1 with procedure codes 59510, 59514, and 59515 to indicate nonelective cesarean sections. |
| U5 | Intrathecal Infusion Pump-Trial (locally defined for physicians) | Providers are required to use modifier U5 with procedure codes 62320, 62321, 62322, and 62323 to indicate trial bolus doses of either baclofen or opioid pain killers. |
| UD |
Clozapine Management (locally defined) |
Providers may use modifier UD with procedure code H0034 only. |
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