Modifier Coding Cheat sheet

Surgical, Gynaecological, Pediatrics & Anesthetic specialists.

Modifier codes at a glance

Name	Rate	Who it applies to
0011 - Emergency / Unscheduled Procedure	12 units per 30 minor part thereof	All members of the surgical team (surgeon + assistant each need their own line)
0018 - High BMI Surgical Modifier	+50%of selected procedures · BMI must exceed 35	Surgeons · Anesthesiologists
0009 - GP / Non-Specialist Assistant Fee	20%min. 36 clinical units — system applies whichever is higher	GP or non-specialist assisting in surgery
0008 - Specialist Surgeon Assistant Fee	40%33.33% for Compensation Fund cases	Registered specialist surgeon assisting
0074 - Endoscopic Procedures — Own Equipment	+33.33%of selected procedures	GPs (014 / 015)
1211 - Cardio-Respiratory Resuscitation	50 units per 30 minmax 150 units · first hour: 50/30 min · thereafter: 25/30 min	All specialties · Must be added as a Modifier line, not a Procedure

Anesthetic & Specialty modifiers at a glance

Code	Name	Rate	Required specialty
0023	Anesthetic Time — Anesthetist	2 units / 15 minfirst hour · 3 units/15 min thereafter · no reduction	010 Anesthetists only
0036	Anesthetic Time — General Practitioner	Same as 0023 ≤ 1hr> 1hr: total reduced to 80%, floor of 11 units	014 GP /015 Specialist Family Medicine. 032 Pediatrician
0039	Control of Blood Pressure	+3 units ≤ 1hr+1 unit per 15 min thereafter	010 Anesthetists · 014/015 GP or Family Medicine · 030 ENT · 032 Pediatrician
0019	Neonate / Low-Birth-Weight Surgery	+50%of selected lines · weight must be < 2.5kg	014/015 GP · 032 Pediatrician

Flat-rate additions

Code	Description	Addition
0006	Visiting specialist performing a procedure	R0.00 by design — flags the claim, no price
0043	Patient under one year of age	+3 anesthetic units
5442	Shoulder / scapula / clavicle / humerus / elbow / upper ⅓ tibia / knee / patella / mandible / TMJ procedures	+2 anesthetic units
5443	Maxillary and orbital bone procedures	+3 anesthetic units
0007	Own monitoring equipment (rooms or theatre)	15 clinical units × RCF
0010	Local anesthetic by the operator	7 anesthetic units × RCF
0017	Subsequent injections, same condition	7.5 consultative units × RCF
0020	Conscious sedation, outside theatre	R0.01 — informational only
0051	Open reduction / internal fixation of fractures	77 clinical units × RCF
0075	Endoscopic procedures, own room + equipment	21 clinical units × RCF
0084	Film costs (radiological items)	R0.01 — enter your own price after

Building a surgical claim

This order is fixed. Skip steps that don't apply — but never reorder the ones that do.

Gynaecology / obstetrics claim Structure Example

Procedure line(s) - Add all surgical procedures first. Modifiers can only reference lines already above them.
If BMI > 35 - 0018 — High BMI modifier Must come before 0009 so it appears in the "Apply to" list when the assistant fee is calculated.
If emergency 0011 — Surgeon's emergency time One line for the surgeon's emergency time.
If assistant present 0009 or 0008 — Assistant fee Added last so all applicable procedures and modifiers (e.g. 0018) are in the Apply to list.
If emergency + assistant 0011 — Assistant's emergency time A separate 0011 line for the assisting doctor — added after 0009/0008, not grouped with the surgeon's 0011. Do not increase the quantity on the surgeon's line.

Pediatrics surgery claim Structure Example

Procedure line(s) Add the pediatrics surgical procedure(s) first.
If neonate / LBW 0019 — Neonate / low-birth-weight addition Directly after the procedure it applies to — must be on the invoice before the assistant fee modifier, or it won't appear in that modifier's Apply to list.
If emergency 0011 — Surgeon's emergency time One line for the surgeon's emergency time.
If assistant present 0009 or 0008 — Assistant fee Added last, applied to the procedure and 0019 — not to 0011, for the same reason as the gynaecology example.
If emergency + assistant 0011 — Assistant's emergency time A separate line for the assisting doctor, added after 0009/0008.

Critical rules

Modifiers are gated by the treating provider's specialty — with no error shown. If the Treating provider doesn't hold the required specialty (e.g. 010 Anesthetists for 0023, 014/015/032 for 0036), Nova adds the modifier line with the correct description but a price of R0.00 and no input modal. Check the treating provider first before assuming a modifier is broken.
Procedures must be added before modifiers. The Apply to list only shows lines already above the modifier on the invoice. Adding a procedure after a modifier means it will be missed from that modifier's calculation.
0018 must come before 0009/0008. If 0018 is added after the assistant fee modifier, it will not appear in the 0009/0008 Apply to list and will be excluded from the assistant fee calculation.
Do not tick 0011 in the 0009 or 0008 Apply to list. The assistant fee is a percentage of surgical procedures (and applicable surgical modifiers like 0018), not of emergency time. Including 0011 will produce an incorrect amount.
Do not increase the quantity on a modifier line. If the same modifier is needed more than once (e.g. two 0011 lines — one for the surgeon, one for the assistant), add a second modifier line. Increasing the quantity produces incorrect results.
0011 applies to unscheduled emergencies only. It does not apply to procedures performed outside normal hours if the patient was on a scheduled theatre list.
0009 and 0018 require surgical procedure codes. If only consultation codes are present, Nova will warn that there are no valid lines to apply the modifier to. Add the surgical procedure line first.
1211 must be added as a Modifier line, not a Procedure line. Medprax classifies cardio-respiratory resuscitation as a modifier code. Adding it as a Procedure will produce incorrect pricing.
For Medscheme claims: the second 0011 must specify the assisting provider. If a claim has both a surgeon's and an assistant's 0011 line, Medscheme requires the assisting provider to be identified on the second and any subsequent 0011 lines.