Effective for dates of service on or after September 22, 2003, Medi-Cal accepts up to four modifiers on the HCFA 1500 claim form and the ASC X12N 837 Version 4010A1 Institutional and Professional formats. Providers must bill as follows for these formats:

• HCFA 1500: Providers bill all modifier values immediately following the procedure code in Box 24D without any spaces.
• ASC X12N 837, Version 4010A1 Professional: SV101-3, SV101-4, SV101-5, SV101-6
• ASC X12N 837, Version 4010A1 Institutional: SV202-3, SV202-4, SV202-5, SV202-6

Additional modifiers cannot be billed on any of the following formats:

• CMC Propriety (all claim types)
• Vision Care paper claims (45-1)
• ASC X12N 837 Version 3041
• Version 4 Flat File