(Medicare Claims Processing Manual)

From 2007 through 2013, HOPDs were required to report modifier FB when appropriate. As discussed in the CY 2007 OPPS final rule (71 FR 68076 through 68077), effective for services furnished on or after January 1, 2007, Medicare reduced the amount of payment for certain APCs when the hospital reported that it received a listed device without cost or where the hospital received a full credit for the cost of a replaced listed device. The reduction applied only when specific devices were replaced. To indicate t hat the hospital received the device without cost, modifier FB must have been reported.    In addition, OPPS hospitals were required to report modifier FB on the same line as the surgical or procedure code (not the HCPCS Level II device code) for a service that required a device for which neither the hospital, nor the beneficiary, was liable to the manufacturer. Similarly, hospitals were required to report modifier FB on the same line as the surgical or procedure code (not the device code) for a service that required a device when the manufacturer gave credit for a device that was replaced with a more costly device.  Refer to section 61.3 of this manual for instructions regarding charges for items billed with the FB modifier.   As of January 1, 2014, modifier FB is no longer required on OPPS claims, and has been replaced with value code FD (credit received from the manufacturer for a replaced medical device) as discussed in the CY 2014 OPPS/ASC final rule (78 FR 75006 through 75007), as well as in section 61.3.6 of this manual.  Specifically, effective January 1, 2014, HOPDs are no longer required to report modifier FB, and instead, must report value code FD to indicate the amount of the credit in the amount portion for value code  FD when the hospital receives a credit for a replaced device that is 50 percent or greater than the cost of the device. For more information on value code FD, refer to MLN Factsheet MLN909368 dated May 2022, which is available on the cms.gov website, specifically, at https://www.cms.gov/Outreach -and-Education/Medicare -Learning -Network -MLN/MLNProducts/Downloads/cardiacdevicecredits -ICN909368.pdf   Although no longer required for OPPS claims, modifier FB is still required on ASC claims.   20.6.10 - Modifier  FC (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FC: Partial credit received for replaced device    A. General   From 2008 through 2013, HOPDs were required to report modifier FC when appropriate. As discussed in the CY 2008 OPPS/ASC final rule (72 FR 66744 through 66749), effective for services furnished on or after January 1, 2008, OPPS hospitals were required to report modifier FC for cases in which the hospital received a partial credit of 50 percent or more of the cost of a new replacement device under warranty, recall, or field action. The hospital must have appended modifier FC to the surgical or procedure code  (not the device code) that reported the services provided to replace the device. Refer to section 61.3 of this manual for instructions regarding charges for items billed with the FC modifier.   As of January 1, 2014, modifier FC is no longer required on OPPS claims, and has been replaced with value code FD (credit received from the manufacturer for a replaced medical device) as discussed in the CY 2014 OPPS/ASC final rule (78 FR 75006 through 75007), as well as in section 61.3.6 of this manual. Specifically, effective January 1, 2014, HOPDs are no longer required to report modifier FC, and instead, must report value code FD to indicate the amount of the credit in the amount portion for value code FD when the hospital receives a credit for a replaced device that is 50 percent or greater than the cost of the device. For more information on value code FD, refer to MLN Factsheet MLN909368 dated May 2022, which is available on the cms.gov website, speci fically, at https://www.cms.gov/Outreach -and-Education/Medicare -Learning -Network -MLN/MLNProducts/Downloads/cardiacdevicecredits -ICN909368.pdf   Although no longer required for OPPS claims, modifier FC is still required on ASC claims.   20.6.11 - Modifier PO  (Rev. 11897; Issued:03- 10-23; Effective:04 -01-23; Implementation:04 -03-23)   PO: Excepted service provided at an off -campus, outpatient, provider -based department of a hospital   As described in the CY 2015 OPPS/ASC final rule (79 FR 66910 through 66914), CMS established HCPCS modifier PO to describe excepted service provided at an off -campus, outpatient, provider -based department of a hospital. This modifier should be reported with every HCPCS code for all outpatient hospital items and services furnished in an excepted off -campus provider -based department of a hospital. See 42 CFR 413.65(a)(2) for a definition of campus.  This modifier should not be reported for remote locations of a hospital (defined at 42 CFR 413.65(a)(2)), satellite facilities of a hospital (defined at 42 CFR 412.22(h)), or for services furnished in an emergency department.   Note that reporting of this modifier was voluntary for CY 2015, but is required beginning January 1, 2016.   We note that, beginning in CY 2019, we finalized a policy to pay for clinic visits (G0463) billed at excepted off -campus provider -based departments (departments that bill modifier PO on their claim lines) at the PFS -equivalent amount. We phased- in this policy in over a two -year period. Specifically, half of the total 60 -percent payment reduction, a 30-percent reduction, was applied in CY 2019. Consequently, these departments were paid 70 percent of the OPPS rate (100 percent of the OPPS rate minus the 30- percent payment reduction that applies in CY 2019) for the clinic visit. In CY 2020, the two -year phase- in was completed. The PFS -equivalent rate for CY 2020 and subsequent years is 40 percent of the proposed OPPS payment (that is, 60 percent less than the  proposed OPPS rate).    Off-campus provider -based departments should not report both the PO and PN modifiers on the same claim line. However, if services reported on a claim reflect items and services furnished from both an excepted and a nonexcepted off -campus PBD of the hospita l, the PO modifier should be used on the excepted claim lines and the PN modifier should be used on the nonexcepted claim lines.  Neither the PO nor the PN modifier is to be reported by the following hospital departments:    A dedicated emergency department as defined in existing regulations at 42 CFR 489.24(b);   A PBD that is on the campus, or within 250 yards, of the hospital or a remote location of the hospital as defined under 42 CFR 413.65.   20.6.12 - Modifier PN  (Rev.  12552; Issued:03- 21-24; Effective:04 -01-24; Implementation:04 -01-24)  PN: Non -excepted service provided at an off -campus, outpatient, provider -based department of a hospital   A. General   In accordance with Section 1833(t)(21) of the Act, as added by section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114- 74), CMS established modifier PN to identify and pay nonexcepted items and services billed on an institutional claim. Effective Jan uary 1, 2017, non- excepted off -campus provider -based departments of a hospital are required to report this modifier on each claim line for non- excepted items and services. The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule (PFS). This modifier must be reported with each nonexcepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services. Nonexcepted items and services are described in the regulations at 42 CFR 419.48.  Off-campus provider -based departments should not report both the PO and PN modifiers on the same claim line. However, if services reported on a claim reflect items and services furnished from both an excepted and a nonexcepted off -campus PBD of the hospita l, the PO modifier should be used on the excepted claim lines and the PN modifier should be used on the nonexcepted claim lines.  Neither the PO nor the PN modifier is to be reported by the following hospital departments:   A dedicated emergency department as defined in existing regulations at 42 CFR 489.24(b);   A PBD that is on the campus, or within 250 yards, of the hospital or a remote location of the hospital as defined under 42 CFR 413.65.  B. Effect on Payment   Payment for nonexcepted items and services furnished at nonexcepted off -campus provider -based departments reported with modifier PN will result in a payment rate under the PFS effective January 1, 2017. The PN modifier is required to be reported on each claim line with each nonexcepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.   C. Payment for Intensive Cardiac Rehabilitation (ICR) Services  Effective January 1, 2024, ICR services furnished by a nonexcepted off -campus provider -based department are excluded from the 40 percent PFS Relativity Adjuster policy.  This exclusion has been implemented at the code level.  Specifically, the claims processing of HCPCS codes G0422 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session) and G0423 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise, per session) have been modified so that 100 percent of the OPPS rate for Cardiac Rehabilitation (CR) is paid irrespective of the presence of the PN modifier on the claim.  20.6.13 - Modifier CT  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  CT: Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 Standard   A. General    In accordance with section 1834(p) of the Act, CMS established modifier CT (Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR -29-2013 standard) effective January 1, 2016, to identify computed tomography (CT) scans that are furnished on equipment that does not meet the National Electrical Manufacturers Association (NEMA) Standard XR -29-2013, titled Standard Attributes on CT Equipment Related to Dose  Optimization and Management.   Modifier CT is required to be reported on claims for computed tomography (CT) scans described by applicable HCPCS codes that are furnished on non- NEMA Standard XR -29-2013- compliant equipment. The applicable CT services are identified by HCPCS codes 70450 through 70498; 71250 through 71275; 72125 through 72133; 72191 through 72194; 73200 through 73206; 73700 through 73706; 74150 through 74178; 74261 through 74263;  and 75571 through 75574 (and any succeeding codes).   HOPDs are reminded that this modifier should not be reported with codes that describe CT scans not listed above.  B.  Effect on Payment   Effective January 1, 2016, the use of this modifier resulted in a payment reduction of 5 percent for the applicable computed tomography (CT) services when the service was paid separately. However, for CY 2017 and subsequent years, the use of this modifier results in a payment reduction of 15 percent for the applicable computed tomography (CT) services when the service is paid separately. The payment reduction is also applied to the APC payment for the HCPCS codes listed above that are subject to the multipl e imaging composite policy.  20.6.14 - Modifier  FX (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FX: X -ray taken using film   A. General