Modifiers

The following performance measurement modifiers may be used for Category II codes to indicate that a service specified in the associated measure(s) was considered but, due to either medical, patient, or system circumstance(s) documented in the medical record, the service was not provided. These modifiers serve as denominator exclusions from the performance measure. The user should note that not all listed measures provide for exclusions (see Appendix H for more discussion regarding exclusion criteria).

Category II modifiers should only be reported with Category II codes-they should not be reported with Category I or Category III codes. In addition, the modifiers in the Category II section should only be used where specified in the guidelines, reporting instructions, parenthetic notes, or code descriptor language listed in the Category II section (code listing and Appendix H).

1P   Performance Measure Exclusion Modifier due to Medical Reasons

Reasons include:

• Not indicated (absence of organ/limb, already received/performed, other)
• Contraindicated (patient allergic history, potential adverse drug interaction, other)
• Other medical reasons

2P   Performance Measure Exclusion Modifier due to Patient Reasons

Reasons include:

• Patient declined
• Economic, social, or religious reasons
• Other patient reasons

3P   Performance Measure Exclusion Modifier due to System Reasons

Reasons include:

• Resources to perform the services not available
• Insurance coverage/payor-related limitations
• Other reasons attributable to health care delivery system

8P   Performance measure reporting modifier -action not performed, reason not otherwise specified

Modifier 8P is intended to be used as a "reporting modifier" to allow the reporting of circumstances when an action described in a measure's numerator is not performed and the reason is not otherwise specified.

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