(Medicare Claims Processing Manual)

DATA RECORD  FIELD # & ITEM  LENGTH & PIC  1 File Year  This field displays the effective year of the file.  4 Pic x(4)  2 A/B MAC (B) Number  This field represents the 5 -digit number assigned to the A/B MAC (B). 5 Pic x(5)  3 Locality  This 2 -digit code identifies the pricing locality used. 2 Pic x(2)  4 HCPCS Code  This field represents the procedure code.  Each A/B MAC (B) Current Procedural Terminology (CPT) code (other than codes for Multianalyte Assays with Algorithmic Analyses (MAAA) and Proprietary Laboratory Analyses (PLA)) and alpha -numeric HCPCS codes other than B, C, E, K, L and U codes will be included.  The standard sort for this field is blanks, alpha, and numeric in ascending order.  Note:  MAAA and PLA are alpha- numeric CPT codes. 5 Pic x(5)  5 Modifier  2 Pic x(2)  FIELD # & ITEM  LENGTH & PIC  For diagnostic tests, a blank in this field denotes the global service and the following modifiers identify the components:  26 = Professional component  TC = Technical component  For services other than those with a professional and/or technical component, a blank will appear in this field with one exception: the presence of CPT modifier - 53 which indicates that separate Relative Value Units (RVUs) and a fee schedule amount have be en established for procedures which the physician terminated before completion.  This modifier is used only with colonoscopy through stoma code 44388, colonoscopy code 45378 and screening colonoscopy codes G0105 and G0121.  Any other codes billed with modi fier - 53 are subject to medical review and priced by individual consideration.  Modifier -53 = Discontinued Procedure -  Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure.  Due to extenuating circumstances, or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. 6 Descriptor  This field will include a brief description of each procedure code.  50 Pic x(50)  7 Code Status  This 1 position field provides the status of each code under the full fee schedule.  Each status code is explained in 30.2.2. 1 Pic x(1)  8 Conversion Factor  This field displays the multiplier which transforms relative values into payment amounts.  The file will contain the conversion factor for the File Year which will reflect all adjustments.  8 Pic 9(4)v9999 9 Update Factor  This update factor has been included in the conversion factor in Field 8.  6 Pic 9(2)v9999 10 Work Relative Value Unit  This field displays the unit value for the physician work RVU.  9 Pic 9(7)v99 FIELD # & ITEM  LENGTH & PIC  11 Filler  9 Pic 9(7)v99 12 Malpractice Relative Value Unit  This field displays the unit value for the malpractice expense RVU.  9 Pic 9(7)v99 13 Work Geographic Practice Cost Indices (GPCIs)  This field displays a work geographic adjustment factor used in computing the fee schedule amount. 5 Pic 99v999 14 Practice Expense GPCI  This field displays a practice expense geographic adjustment factor used in computing the fee schedule amount. 5 Pic 99v999 15 Malpractice GPCI  This field displays a malpractice expense geographic adjustment factor used in computing the fee schedule amount. 5 Pic 99v999 16 Global Surgery  This field provides the postoperative time frames that apply to payment for each surgical procedure or another indicator that describes the applicability of the global concept to the service.  000 = Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payab le. 010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10- day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure a nd during this 10- day postoperative period generally not payable.  090 = Major surgery with a 1- day preoperative period and 90- day postoperative period included in the fee schedule payment amount. MMM = Maternity codes; usual global period does not apply. XXX = Global concept does not apply. YYY = A/B MAC (B)  determines whether global concept applies and establishes postoperative period, if appropriate, at time of pricing. 3 Pic x(3)  FIELD # & ITEM  LENGTH & PIC  ZZZ = Code related to another service and is always included in the global period of the other service.  (Note: Physician work is associated with intra -service time and in some instances the post service time.)  17 Preoperative Percentage (Modifier 56)  This field contains the percentage (shown in decimal format) for the preoperative portion of the global package.  For example, 10 percent will be shown as 010000.  The total of fields 17, 18, and 19 will usually equal one.  Any variance is slight and resul ts from rounding. 6 Pic 9v9(5)  18 Intraoperative Percentage (Modifier 54)  This field contains the percentage (shown in decimal format) for the intraoperative portion of the global package including postoperative work in the hospital.  For example, 63 percent will be shown as 063000.  The total of fields 17, 18, and 19 will usually equal one.  Any variance is slight and res ults from rounding.  6 Pic 9v9(5)  19 Postoperative Percentage (Modifier 55)  This field contains the percentage (shown in decimal format) for the postoperative portion of the global package that is provided in the office after discharge from the hospital.  For example, 17 percent will be shown as 017000.  The total of fields 17, 18, and 19 will usually equal one.  Any variance is slight and results from rounding. 6 Pic 9v9(5)  20 Professional Component (PC)/Technical Component (TC) Indicator  0 = Physician service codes: This indicator identifies codes that describe physician services.  Examples include visits, consultations, and surgical procedures.  The concept of PC/TC does not apply since physician services cannot be split into professional  and technical components.  Modifiers 26 & TC cannot be used with these codes.  The total Relative Value Units (RVUs) include values for physician work, practice expense and malpractice expense.  There are some codes with no work RVUs. 1 = Diagnostic tests or radiology services: This indicator identifies codes that describe diagnostic tests, e.g., pulmonary function tests, or therapeutic radiology procedures, e.g., radiation therapy.  These codes generally have both a professional and te chnical component.  Modifiers 26 and TC can be used with these codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense.  1 Pic x(1)  FIELD # & ITEM  LENGTH & PIC  The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only.  The total RVUs for codes reported without a modifier equals the sum of RVUs for both the professional and technical component. 2 = Professional component only codes: This indicator identifies stand alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test onl y and another associated code that describes the global test.  An example of a professional component only code is 93010, Electrocardiogram; interpretation and report.  Modifiers 26 and TC cannot be used with these codes.  The total RVUs for professional component only codes include values for physician work, practice expense, and ma lpractice expense.  3 = Technical component only codes: This indicator identifies stand alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional compo nent of the diagnostic tests only. An example of a technical component code is 93005, Electrocardiogram, tracing only, without interpretation and report.  It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code.  Modifiers 26 and TC cannot be used with these codes.  The total RVUs for technical component only codes include values for practice expense and malpractice expense only.  4 = Global test only codes: This indicator identifies stand alone codes for which there are associated codes that describe: a) the professional component of the test only and b) the technical component of the test only.  Modifiers 26 and TC cannot be used with these codes.  The total RVUs for global procedure only codes include values for physician work, practice expense, and malpractice expense.  The total RVUs for global procedure only codes equals the sum of the total RVUs for the professional and techni cal components only codes combined.  5 = Incident to codes: This indicator identifies codes that describe services covered incident to a physicians service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision.  Payment may not be made by A/B MACs (B) for these services when they are provided to hospital inpatients or patients in a hospital outpatient department.  Modifiers 26 and TC cannot be used with these codes.  FIELD # & ITEM  LENGTH & PIC  6 = Laboratory physician interpretation codes: This indicator identifies clinical laboratory codes for which separate payment for interpretations by laboratory physicians may be made.  Actual performance of the tests is paid for under the lab fee schedule.   Modifier TC cannot be used with these codes.  The total RVUs for laboratory physician interpretation codes include values for physician work, practice expense and malpractice expense.  7 = Private practice therapists service:  Payment may not be made if the service is provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or speech -language pathologist in private practice.  8 = Physician interpretation codes: This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  This applies only to code 85060.  No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to hospital outpatients or non- hospital patients.  The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test.  9 = Concept of a professional/technical component does not apply. 21 Multiple Procedure (Modifier 51)  Indicator indicates which payment adjustment rule for multiple procedures applies to the service.  0 = No payment adjustment rules for multiple procedures apply.  If procedure is reported on the same day as another procedure, base payment on the lower of: (a) the actual charge or (b) the fee schedule amount for the procedure. 1 = Standard payment adjustment rules in effect before January 1, 1996, for multiple procedures apply.  In the 1996 MPFSDB, this indicator only applies to codes with procedure status of D. If a procedure is reported on the same day as another procedure w ith an indicator of 1,2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 25 percent, 25 percent, 25 percent, and by report).  Base payment on the lower of: (a) the actual charge or  (b) the fee schedule amount reduced by the appropriate percentage.  2 = Standard payment adjustment rules for multiple procedures apply.  If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee 1 Pic (x)1  FIELD # & ITEM  LENGTH & PIC  schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report).  Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate pe rcentage.  3 = Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).  The base procedure for each code with this indicator is identified in f ield 31G. Apply the multiple endoscopy rules to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non- endoscopic procedure).  If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure.  Payment for the base procedure is included in the payment for the other endoscopy.  4 = Subject to 25% reduction of the TC diagnostic imaging (effective for services January 1, 2006 through June