Policy Statement
There is a significant increase in work intensity for procedures performed on infants less than 4kg related to temperature control, obtaining IV access, and the operation itself, which is technically more difficult regarding maintenance of homeostasis. The submission of Modifier 63 on an appropriate CPT code indicates that the infant’s weight is under 4kg at the time the service is rendered, and this low weight resulted in increased work or complexity of work.
Unless otherwise designated below, modifier 63 is valid with:
- CPT codes 20100–69990 (See table 1 below for codes within this range that cannot be billed with modifier 63).
- Medicine/Cardiovascular codes 92920, 92928, 92953, 92960, 92986, 92987, 92990, 92997, 92998, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93452, 93505, 93563, 93564, 93568, 93569, 93573, 93574, 93575, 93580, 93581, 93582, 93590, 93591, 93592, 93593, 93594, 93595, 93596, 93597, 93598, 93615, 93616
Therefore, Modifier 63 is not valid with Evaluation and Management services, anesthesia, radiology, pathology/laboratory, or medicine codes (other than those listed above).
Medical records may be requested for review to support the additional payment. Documentation from the patient’s record must indicate the significantly greater effort required and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort.
The following codes are Modifier 63 exempt (Do not append modifier 63):
