(Medicare Claims Processing Manual)

FX: X -ray taken using film   A. General    Consistent with the requirements set forth in section 1833(t)(16)(F)(i), and in accordance with provisions allowed under section 1833(t)(16)(F)(iv) of the Act, CMS established modifier FX to identify imaging services that are x -rays taken using film. As stated in the CY 2017 OPPS/ASC final rule (81 FR 79729 through 79730), hospitals are required to use this modifier to report imaging services that are X -rays taken using film eff ective January 1, 2017.   B. Effect on Payment   Payment for x- ray services taken using film reported with modifier FX will be reduced by 20 percent effective January 1, 2017. We note that when payment for an x- ray service taken using film is packaged into the payment for another item or service under the OPPS, no separate payment for the x- ray service taken using film is made. Accordingly, the payment reduction in this instance would be 0 percent (that is, 20 percent of $0). All imaging services that are x -rays are listed in the OPPS Addendum B, which is  available via the Internet on the CMS Web site.   20.6.15  Modifier  FY (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FY: X -ray taken using computed radiography technology/cassette -based imaging   A. General    Consistent with the requirements set forth in section 1833(t)(16)(F)(ii) and in accordance with provisions allowed under section 1833(t)(16)(F)(iv) of the Act, CMS established modifier FY to identify an imaging service that is an X -ray taken using computed radiography technology. Effective January 1, 2018, hospitals are required to use this modifier to report imaging services that are X -rays taken using computed radiography technology.  B. Effect on Payment   Payment for x- ray services taken using computed radiography technology will be reduced by 7 percent from January 1, 2018, through December 31, 2022, and thereafter to 10 percent beginning January 1, 2023. We note that when payment for an x- ray service taken using computed radiography technology is packaged into the payment for another item or service under the OPPS, no separate payment for the x -ray service taken using computed radiography technology is made. Accordingly, the payment reduction in this instance would be 0 percent (that is, 20 percent of $0). All imaging services that are x- rays are listed in the OPPS Addendum B, which is available via the Internet on the CMS Web site.  20.6.16- Modifier  JG (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  JG: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes   A. General   On January 1, 2018, CMS established HCPCS Level II modifier JG to identify and pay 340B -acquired drugs and biologicals. Specifically, beginning January 1, 2018, hospitals paid under the OPPS that are not excepted from the 340B drug payment adjustment, and beginning January 1, 2019, nonexcepted off -campus PBDs of a hospital (that is not otherwise excepted from the 340B drug payment adjustment) paid under the PFS are required to report modifier JG on the same claim line as the drug or biological HCPCS code to  identify if a drug or biological was acquired under the 340B Program. The phrase acquired under the 340B Program is inclusive of all drugs and biologicals acquired under the 340B Program or PVP, regardless of the level of discount applied to the drug.  Effective January 1, 2023, the JG modifier is required to be used by hospitals (except for rural sole community hospitals, childrens hospitals, and PPS -exempt cancer hospitals) to identify 340B drugs for informational purposes only, with no effect on paym ent.  B. Effect on Payment   Starting in CY 2018, payment for certain drugs and biologicals (reported with status indicator K) acquired through the 340B Program that are furnished by providers paid under the OPPS, and beginning January 1, 2019, payment for certain drugs and biologic als furnished by nonexcepted off -campus PBDs of a hospital paid under the PFS (departments that bill modifier PN on their claim lines), were required to report modifier JG on the same claim line as the drug or biological HCPCS code to identify if a drug or  biological was acquired under the 340B Program, which triggered a payment adjustment such that the 340B -acquired drug is paid at the drugs average sales price minus 22.5 percent (or equivalent payment rate derived from the ASP methodology). Starting September 28th, 2022, CMS revised the OPPS drug files that will apply the default rate (generally ASP plus 6 percent) to 340B -acquired drugs for the rest of that calendar year.   Effective January 1, 2023, the presence of modifier JG on a claim to indicate a dr ug is acquired under the 340B program will not trigger a payment reduction and will be used only for informational purposes. Claims for 340B drugs and biologicals identified with a JG modifier will be paid at the same statutory default rate as non -340B drugs and biologicals.   A document explaining the use of this modifier is available via the Internet on the CMS Web site at https://www.cms.gov/files/document/part- b-inflation -rebate -guidance340b-modifierfinal.pdf .  20.6.17 - Modifier TB  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes for select entities   A. General   On January 1, 2018, CMS established HCPCS Level II modifier TB to facilitate the collection and tracking of 340B claims data for OPPS providers that are excepted from the 340B payment adjustment in CY 2018. Beginning January 1, 2019, modifier TB shall be reported by both select hospitals paid under the OPPS and by nonexcepted off -campus PBDs of a hospital paid under the PFS if a drug or biological was acquired under the 340B Program. The phrase acquired under the 340B Program is inclusive of all drugs and biologicals acquired under the 340B Program or PVP, regardless of the level of discount applied to the drug.  Effective January 1, 2023, the TB modifier will be used by rural sole community hospitals, childrens hospitals, and PPS -exempt cancer hospitals to identify 340B drugs for informational purposes. Additionally, all pass -through drugs (reported with the stat us indicator G) purchased through the 340B drug discount program will report with the modifier TB by all OPPS providers.    B. Effect on Payment   From CY 2018 through CY 2022, rural SCHs, childrens hospitals, and PPS -exempt cancer hospitals providers that were exempt from the 340B drug payment adjustment reported the informational modifier TB to identify OPPS separately payable drugs (reported with  status indicator K) purchased through the 340B discount program. The use of modifier TB did not trigger a payment adjustment, and these providers received and will continue to receive ASP plus 6 percent (or equivalent payment rate derived from the ASP m ethodology) for separately payable drugs furnished by these select providers. Furthermore, between CY 2019 and CY 2022, nonexcepted off -campus PBDs paid under the PFS (departments that bill the modifier PN on their claim lines) that furnished 340B -acquired  drugs and biologicals and were exempt from the 340B payment adjustment (because their hospital is a rural SCH or childrens hospital) were required to bill under the PFS using the institutional claim form and report the informational modifier TB for 340B -acquired drugs and biologicals, which did not trigger a payment adjustment, and these providers received ASP+6 percent for separately payable drugs furnished in CY 2019, even if such drugs were acquired under the 340B Program.  For CY 2023, the presence of modifier TB on a claim to indicate a drug is acquired under the 340B program will continue to not trigger a payment reduction and be used only for informational purposes. Claims for 340B drugs and biologicals identified with a TB modifier will be paid at the same statutory default rate as non -340B drugs and biologicals. Additionally, the requirement of the TB modifier to identify drugs acquired through the 340B Program complies with certain requirements of the Inflation Reduction Act because these modifiers are an established mechanism that have been in use by hospitals paid under the OPPS. The Inflation Reduction Act establishes a Part B inflation rebate by manufacturers for certain single source drugs and biologicals with prices increasing faster than the rate of inflation. However, it also specifically excludes units of drugs for which the manufacturer provides a discount under the 340B program from the units of drugs for which a manufacturer otherwise may have a Part B inflation rebate liability.   A document explaining the use of this modifier is available via the Internet on the CMS Web site at https://www.cms.gov/files/document/part- b-inflation -rebate -guidance340b-modifierfinal.pdf .  20.6.18  Modifier  ER  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  ER: Items and services furnished by a provider- based, off -campus emergency department    Effective January 1, 2019, hospitals were required to report HCPCS modifier ER on every claim line that contains a CPT/HCPCS code for an outpatient hospital service furnished in an off -campus provider -based emergency department. This modifier is required t o be reported in provider -based off -campus emergency departments that meet the definition of a dedicated emergency department as defined in 42 Code of Federal Regulations (CFR) 489.24 under the Emergency Medical Treatment and Labor Act (EMTALA) regulatio ns. Per 42 CFR 489.24, a dedicated emergency department means any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus, that meets at least one of the following requirements:   (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;   (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or   (3) During the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one -third of a ll of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.  This modifier would be reported on the UB 04 form (CMS Form 1450) for hospital outpatient services. Reporting of this modifier is not required for Critical access hospitals (CAHs). While this modifier is required, it does not have an effect on payment.   20.6.19 - Modifier CG                                                    (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  CG: Policy criteria applied   Effective January 1, 2019, modifier CG can be reported with certain device -intensive procedures to reflect situations in which a device was not used during the device -intensive procedure.  Refer to section 61.2.1 of this manual for further information on modifier CG.   This modifier would be reported on the UB 04 form (CMS Form 1450) for hospital outpatient device - intensive procedures. Reporting of this modifier is not required for Critical access hospitals (CAHs). While this modifier is required, it does not have an effect on payment.   20.7 - Billing of C HCPCS Codes by Non -OPPS Providers (Rev. 976, Issued: 06- 09-06, Effective: 10 -01-06, Implementation: 10- 02-06)