Revisions to Modifier Reimbursement Table
To align with industry standards, including Medicare, Sanford Health Plan is revising reimbursement amounts for select modifiers. The new reimbursement amounts, effective for claims processed on or after Nov. 1, 2025, are outlined in the table below.
The next publication of the Sanford Health Plan Provider Manual will include these updates as well.
For more information on Medicare’s reimbursement modifiers please refer to the Medicare Claims Processing Manual.
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Modifier Payment Rules |
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Modifier & Description |
Commercial |
Medicare Advantage (Effective Jan. 1, 2026 for Sanford Health Plan) |
Medicaid (Wisconsin only) |
Family Health Center (Wisconsin only) |
|
22 – Increased Procedural Services |
120% of fee schedule |
120% of fee schedule |
As allowed for DME, vision, and hearing per ForwardHealth Fee Schedule |
120% of fee schedule |
|
50 – Bilateral Procedure |
150% of fee schedule or 75% of contracted allowable, unless otherwise agreed to |
150% of Fee Schedule |
As allowed per ForwardHealth Fee Schedule |
As allowed per ForwardHealth Fee Schedule |
|
51 – Multiple Procedures |
50% of base fee |
50% of base fee |
50% of base fee |
50% of base fee |
|
52 – Reduced Services |
50% of base fee |
50% of base fee |
As allowed per ForwardHealth Fee Schedule |
50% of base fee |
|
53 - Discontinued Procedure |
50% of base fee |
50% of base fee |
50% of base fee |
50% of base fee |
|
54 – Surgical Care Only |
80% of base fee |
Follows CMS Guidelines |
As allowed per ForwardHealth Fee Schedule See Topic #572 |
80% of base fee |
|
55 – Post Op Management Only |
20% of base fee |
Follows CMS Guidelines |
Reimburse a per diem per day to each provider who provided post-op care See Topic #572 |
20% of base fee |
|
56 – Pre Op Management Only |
0% of base fee |
Follows CMS Guidlines |
Not separately reimbursable Topic #572 |
0% of base fee |
|
62 – Two Surgeons |
62.5% of base fee |
62.5% of base fee |
As allowed for DME per ForwardHealth Fee Schedule Topic #656 |
62.5% of base fee |
|
63 – Procedure Performed on Infants < 4kg |
100% of fee schedule |
Does not affect payment |
Does not affect payment |
100% of fee schedule |
|
80 Assistant Surgeon |
16% of fee schedule |
16% of fee schedule |
20% of FowardHealth Fee Schedule Topic #656 & 578 |
16% of fee schedule |
|
81 – Minimum Assistant Surgeon |
16% of fee schedule |
16% of fee schedule |
20% of FowardHealth Fee Schedule Topic #656 & 578 |
16% of fee schedule |
|
82 – Assistant Surgeon (when qualified resident surgeon not available ) |
16% of fee schedule |
20% of fee schedule |
16% of fee schedule |
16% of fee schedule |
|
AS – PA, NP or clinical nurse specialist services for assistant at surgery |
16% of physician base fee |
16% of physician base fee |
20% of FowardHealth Fee Schedule Topic #656 & 578 |
16% of physician base fee |
|
CO – OP OT services furnished in whole or part by OTA |
85% of fee schedule |
85% of fee schedule |
As allowed per ForwardHealth Fee Schedule |
85% of fee schedule |
|
CQ – OP OT services furnished in whole or part by PTA |
85% of fee schedule |
85% of fee schedule |
As allowed per ForwardHealth Fee Schedule
|
85% of fee schedule |
|
P3 – A patient with severe systemic disease |
No additional payment |
No additional payment |
No additional payment |
No additional payment |
|
P4 – a patient with severe systemic disease that is a constant threat to life |
No additional payment |
No additional payment |
No additional payment |
No additional payment |
|
P5 – A moribund patient who is not expected to survive without the operation |
No additional payment |
No additional payment |
No additional payment |
No additional payment |