Modifier 63; Procedure Performed on Infants Less Than 4 kg

Policy No: 110
Originally Created: 09/01/2009
Section: Modifiers
Last Reviewed: 02/01/2024
Last Revised: 02/01/2024
Approved: 02/08/2024
Effective: 03/01/2024

This policy applies only to physicians and other qualified health care professionals.

Definitions

Modifier 63 - Procedure performed on infants less than 4kg
Current Procedural Terminology (CPT©) modifier 63 represents procedures performed on neonates and infants up to a present body weight of 4kg.

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 to 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, with exception to modifier 63 exempt codes.
  • 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 codes in the following table are modifier 63 exempt (Do not append modifier 63):

Modifier 63 exempt

Do not append modifier 63

30540

33946

46735

30545

33947

46740

31520

33948

46742

33502

33949

46744

33503

36415

47700

33505

36420

47701

33506

36450

49215

33610

36456

49491

33611

36460

49492

33619

36510

49495

33647

36660

49496

33670

39503

49600

33690

43313

49605

33694

43314

49606

33730

43520

49610

33732

43831

49611

33735

44055

53025

33736

44126

54000

33741

44127

54150

33750

44128

54160

33755

46070

63700

33762

46705

63702

33778

46715

63704

33786

46716

63706

33922

46730

65820

When a provider reports an eligible procedure or service with modifier 63 appended, reimbursement will be 120% of the established fee.

Modifiers 63 and 22 cannot be billed on the same code.

References

American Medical Association. Appendix A: Modifiers, CPT©, Chicago, AMA Press.

American Medical Association. Appendix F: Summary of CPT Codes Exempt from Modifier 63. CPT©, Chicago, AMA Press.

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.