Medicine and Surgery Section - Wisconsin.gov

Appendix 2
Allowable Modifiers for Physician Evaluation and Management, Medicine,
and Surgery Services
Wisconsin Medicaid accepts nationally recognized modifiers on claims and other forms, when applicable. The following table
lists Medicaid-allowable modifiers for physician evaluation and management, medicine, and surgery services providers.
Note: Wisconsin Medicaid accepts all valid modifiers; however, not all modifiers are allowed by Wisconsin Medicaid’s
claims processing system.
Modifier Description Notes
26 Professional component
50 Bilateral procedure
54 Surgical care only
55
Postoperative management
only
80 Assistant surgeon
AQ
Physician providing service in
a HPSA
TC Technical component
TH
TJ
Obstetrical treatment/
services, prenatal or
postpartum
Program group, child and/or
adolescent
Refer to Appendix 1 of this section for procedure codes for which modifier “26”
is allowable.
Use of modifier "50" is allowed for those procedures for which the concept is
considered appropriate according to standard coding protocols and Healthcare
Procedure Coding System or Current Procedural Terminology definitions. Refer
to the physician maximum allowable fee schedule for procedures in which this
modifier is allowable.
Use of modifier “54” is allowed only for cataract surgery procedure codes
66820-66821, 66830-66984 for preoperative care and surgery when postoperative
care is performed by an optometrist. The surgeon is reimbursed at 90
percent of global maximum allowable fee for preoperative care and minor
surgery or 80 percent for preoperative care and major surgery.
Use of modifier “55” is allowed only for cataract surgery procedure codes
66820-66821, 66830-66984 for postoperative care when performed by an
optometrist.
Use of modifier "80" is allowed for those surgery procedures recognized as
accepted medical practice. Modifier “80” should be used regardless of the type
of performing provider.
Refer to the physician fee schedule for procedures for which this modifier is
allowable.
Providers receive enhanced reimbursement when services are performed in a
Health Professional Shortage Area (HPSA). Refer to Appendix 25 of this section
for a list of HPSA-eligible procedure codes.
Refer to Appendix 1 of this section for procedure codes for which modifier “TC”
is allowable.
Providers are required to use modifier "TH" with procedure codes 99204 and
99213 only when those codes are used to indicate the first three antepartum
care visits.
Providers are required to use both modifiers "TH" and “AQ” when these
prenatal services are HPSA eligible.
Providers may use modifier "TJ" with procedure codes 99201-99215 and
99281-99285 only for recipients 18 years of age and younger. Providers should
not bill the HPSA modifier with modifier “TJ.”
Physician Services Handbook — Medicine and Surgery December 2005 73
Appendix