This article delves into modifier 63, a key piece for dealing with the smallest patients, infants weighing less than 4 kg.  Modifier 63 addresses the additional time, complexities, and challenges of treating infants under 4kg or about 8.8 pounds.  To put this in perspective, 4kg or 4000 grams is equivalent to a small pumpkin.

Why Use Modifier 63?

Providers using modifier 63 may receive additional reimbursement. Therefore, it’s important that the documentation reflects both the accuracies of the infant’s weight, as well as the difficulties present during the course of care.  Proper billing not only results in maximized revenue, but also ensures fair and accurate compensation for the care provided. Some payers note in their policies that when modifier 63 is used it results in 120% of the normal allowance.[1]

How Should Modifier 63 be Documented?

Examples of what the documentation should reflect include, but are not limited to:

  • The weight of the infant at the time the service was rendered.
  • Justification that the lower weight of the infant resulted in increased time and complexity of the care provided.
  • Any indications regarding the severity of the patient’s condition.

What to look for?

Always check your respective plan policies and/or contracts. There are many data points and specific data patterns that should be reviewed to identify potentially improper billing[2]. Below are just some examples:

  • Modifier 63 is only appropriate with codes in the Surgery section and some codes in the Medicine/Cardiovascular section.
  • Per AMA, in general, modifier 63 cannot be appended to codes involving congenital anomalies or that have increased complexity associated with prematurity valued in the code.
  • Reference Appendix F of the AMA CPT book which lists 75 codes NOT to be used with modifier 63.
  • Look for excessive billing of modifier 63 within a provider’s own patient population.
  • Look for excessive billing of modifier 63 compared to other providers.

If you are using the HCFSPlatform™, HCFS has you covered. Our 1700+ library of alerts used in combination with our artificial intelligence detects known and unknown schemes. HCFS captures known schemes involving Modifier 63 with both our AI and with alerts such as: