Get the Facts about Modifier QQ

New HCPCS Level II modifier reports advanced diagnostic imaging provided to Medicare patients.

The Centers for Medicare & Medicaid Services (CMS) created a new modifier to report use of a clinical decision support mechanism (CDSM) prior to ordering an advanced diagnostic imaging service for a Medicare patient.

Look to Recent CMS Guidance

As detailed in MLN Matters® MM10481:

The Protecting Access to Medicare Act (PAMA) of 2014, Section 218(b), established a new program to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. Examples of such advanced imaging services include computerized tomography, positron emission tomography, nuclear medicine, and magnetic resonance imaging.

Under PAMA, providers ordering advanced diagnostic imaging services for a Medicare patient are required to consult a CDSM electronic portals through which practitioners access appropriate use criteria (AUC). Essentially, AUC tell the ordering provider whether the advanced diagnostic imaging service is appropriate, given the patient’s circumstances.
Full implementation of PAMA is expected in early 2020; however, beginning July 1, 2018, providers ordering advanced diagnostic imaging services for Medicare patients may voluntarily consult qualified CDSMs and report that information on Medicare claims using new modifier QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional.

How to Apply Modifier QQ

Modifier QQ is applied when the provider furnishing the advanced diagnostic imaging services knows the result of the ordering professional’s consultation with a CDSM for that patient. The modifier is reported on both the facility and professional claim, on the same claim line as the CPT® code for an advanced diagnostic imaging service furnished in an applicable setting. Applicable settings include physician offices, hospital outpatient departments, and ambulatory surgical centers.
Note: The applicable setting is where the imaging service is furnished, not where it is ordered.

Append QQ to Certain Codes

Per CMS in MM10481, Medicare Administrative Contractors (MACs) will accept modifier QQ with the following CPT® codes:

Magnetic Resonance Imaging

70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 76498

Computerized Tomography

70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74712, 74713, 75571, 75572, 75573, 75574, 75635, 76380, 76497

Single-Photon Emission Computed Tomography

76390

Nuclear Medicine

78012, 78013, 78014, 78015, 78016, 78018, 78020, 78070, 78071, 78072, 78075, 78099, 78102, 78103, 78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78185, 78191, 78195, 78199, 78201, 78202, 78205, 78206, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78267, 78268, 78270, 78271, 78272, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78320, 78350, 78351, 78399, 78414, 78428, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610, 78630, 78635, 78645, 78647, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78710, 78725, 78730, 78740, 78761, 78799, 78800, 78801, 78802, 78803, 78804, 78805, 78806, 78807, 78811, 78812, 78813, 78814, 78816, 78999
Until further notice, MACs will continue to pay claims for these services, regardless of whether modifier QQ is appended. In the future, however, providers who order advanced imaging services in the absence of, or contrary to, appropriate use criteria, may be subject to prepayment review.

Mahalakshmi Vaithilingam, COC, CPC, is a team leader in clinical coding and analytics for SCIO Health Analytics. She has a professional degree in physical therapy. Vaithilingam has more than 10 years of experience in medical coding, with multispecialty expertise in radiology, evaluation and management, and surgery. She is a member of the Chennai, India, local chapter.
Resources
MLN Matters® MM10481: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10481.pdf
CMS Transmittal 2040: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2040OTN.pdf