Reminders regarding required billing of modifiers

As you’re aware, it’s important to include modifiers on a claim whenever appropriate to provide additional information to describe the encounter in better detail. We’re offering the reminders below regarding certain types of encounters or scenarios for which the inclusion of modifiers is required in the interest of industry standard correct coding.

Drugs with multiple routes of administration

When reporting drugs that have only one HCPCS Level II (J or Q) code but multiple potential routes of administration, providers must append one of the following modifiers to denote the route of administration:

  • JA: Administered intravenously
  • JB: Administered subcutaneously

End stage renal disease and erythropoiesis-stimulating agents

When billing for end stage renal disease and erythropoiesis-stimulating agents, you’re required to append the following modifiers, as appropriate:

  • EA: Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy
  • EB:  Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy
  • EC: ESA administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy

Positron Emission Tomography (PET) services

Providers reporting PET services with an oncological diagnosis must append the following modifiers:

  • PI : Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
  • PS: Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the PET study is needed to inform subsequent antitumor strategy

Please keep in mind that failure to append the modifiers referenced above when applicable may result in a claim denial.