(Medicare Claims Processing Manual)

A. General   Effective January 1, 2017, the definition of modifier PN is  Nonexcepted service provided at an off -campus, outpatient, provider -  based department of a hospital . This modifier was established to  identify and pay nonexcepted items and services billed by an off-campus department of a provider.  Nonexcepted items and services are described in the regulations at 42 CFR 419.48.  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 pay ment 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.  A table of PFS payment for nonexcepted items and services in nonexcepted off-campus provider- based departments of a hospital by OPPS status indicator is available via the Internet on the CMS Web site at https://www.cms.gov/Medicare/Medicare -F ee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2018- PFS-FR-Nonexcepted -Items.zip .   20.6.13 - Use of HCPCS Modifier  CT (Rev. 3941; Issued: 12- 22-17; Effective: 01- 01- 18; Implementation: 01 -02-18)  Effective January 1, 2016, the definition of modifier  CT is 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.  This modifier 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).   This modifier should not be reported with codes that describe CT scans not listed above.  20.6.14 - Use of HCPCS Modifier  FX (Rev. 3941; Issued: 12- 22-17; Effective: 01- 01- 18; Implementa tion: 01 -02-18)  A. General  On December 18, 2015, the Consolidated Appropriations Act of 2016  was signed into law (Public Law 114-113).  Section 502 of the Consolidated Appropriations Act requires that Medicare implement the following provisions under the hospital outpatient prospective payment system (OPPS):  reduce payment by 20 percent for an X -ray taken using film and that is furnished beginning January 1, 2017, and reduce payment by 7 percent from January 1, 2018 through December 31, 2022, and thereafter to 10 percent beginning January 1, 2023 for an imaging service that is an x-ray taken using computed radiography technology.   Effective January 1, 2017, the definition of modifier FX is  X-ray taken using film.  This modifier is required to be reported on claims for imaging services that are x -rays using film.    B. Effect on Payment    Paymen t 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 a vailable via the Internet on the CMS Web site.    20.6.15 - Use of HCPCS Modifier  FY (Rev. 3941; Issued: 12- 22-17; Effective: 01- 01- 18; Implementation: 01 -02-18)  A. General  On December 18, 2015, the Consolidated Appropriations Act of 2016  was signed into law (Public Law 114-113).  Section 502 of the Consolidated Appropriations Act requires that Medicare implement the following provisions under the hospital outpatient prospective payment system (OPPS):  reduce payment by 20 percent for an x -ray taken using film and that is furnished beginning January 1, 2017, and reduce payment by 7 percent from January 1, 2018 through December 31, 2022, and thereafter to 10 percent beginning January 1, 2023 for an x-ray taken using computed radiography technology.   Effective January 1, 2017, the definition of modifier FY is  X-ray taken using computed radio graphy technology/cassette-based imaging. This modifier is required to be reported on claims for imaging services that are x -rays taken using computed radiography technology/cassette- based imaging.   B. Effect on Payment  Payment for x -ray services taken u sing 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  - Use of HCPCS Modifier  JG (Rev. 4204, Issued: 01- 17-19, Effective: 01-01-19, Implementation: 01-07-19)   A. General   Effective January 1, 2018, CMS established a new HCPCS Level II modifier, modifier JG, to identify and pay 340B-acquired drugs and biologicals. The definition of modifier JG is Drug or biological acquired with 340B drug pricing program discount. 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. This requirement is aligned with the m odifier requirement already mandated in several States under their Medicaid programs. The phrase acquired under the 340B Program is inclusive of all drugs acquired under the 340B Program or PVP, regardless of the level of discount applied to the drug.   B. Effect on Payment  Effective January 1, 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 biologicals furnished by nonexcepted off- campus PBDs of a hospital paid under the PFS (departments that bill modifier PN on their claim lines), are required to report modifier JG on the same claim line as the drug or biological HCPC S code to identify if a drug or biological was acquired under the 340B Program, which will trigger a payment adjustment such that the 340B-acquired drug is paid at the drugs average sales price minus 22.5 percent. A document explaining the use of this modifier is available via the Internet on the CMS Web site at https://www.cms.gov/Medicare/Medicare -Fe e-for-Service-Payment/HospitalOutpatientPPS/Downloads/Billing -340B- Modifiers -under-Hospital-OPPS.pdf .  20.6.17  - Use of HCPCS Modifier  TB  (Rev. 4204, Issued: 01- 17-19, Effective: 01-01-19, Implementation: 01-07-19)   A. General   Effective January 1, 2018, CMS established a new HCPCS Level II modifier, 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. The definition of modifier TB is Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes. Beginning January 1, 2019, modifier TB shall be reported by both hospitals paid under the OPPS and by nonexcepted off-campus PBDs of a hospital paid under the PFS if the hospital is excepted from the 340B drug payment adjustment to identify if a drug or biological was acquired under the 340B Program.   B. Effect on Payment  Effective January 1, 2018, providers that are exempt from the 340B drug payment adjustment including, rural SCHs, childrens hospitals, and PPS- exempt cancer hospitals, shall report the informational modifier TB to identify OPPS separately payable drugs (reported with status indicator K) purchased with a 3 40B discount. The informational modifier TB will facilitate the collection and tracking of 340B claims data for OPPS providers that are excepted from the payment adjustment. However, use of modifier TB will not trigger a payment adjustment and these pr oviders will receive ASP+6 percent for separately payable drugs furnished in CYs 2018 and 2019, even if such drugs were acquired under the 340B Program. Furthermore, beginning January 1, 2019, nonexcepted off-campus PBDs paid under the PFS (department tha t bill the modifier PN on their claim lines) that furnish 340B-acquired drugs and biologicals and are exempt from the 340B payment adjustment (because their hospital is a rural SCH or childrens hospital) will be required to bill under the PFS using the institutional claim form and report the informational modifier TB for 340B-acquired drugs and biologicals, which will not trigger a payment adjustment, and these providers will continue to receive ASP+6 percent for separately payable drugs furnished in CY 2019, even if such drugs were acquired under the 340B Program. A document explaining the use of this modifier is available via the Internet on the CMS Web site at https://www.cms.gov/Medicare/Medicare -Fe e-for-Service -Payment/HospitalOutpatientPPS/Downloads/Billing -340B- Modifiers -under-Hospital-OPPS.pdf .  20.6.18 - Use of HCPCS Modifier - ER  (Rev. 4255, Issued: 03- 15-19, Effective: 04-01-19, Implementation: 04-01-19)    Effective January 1, 2019, the definition of modifier - ER is  Items and services furnished by a provider -based off- campus emergency department. This modifier is required to be reported on every claim line that contains a CPT/HCPCS code for an outpatient hospital service furnished in an off-campus provider-based emergency department. See 42 CFR 413.65(a)(2) for a definition of campus.   This modifier would be reported on the UB04 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 - Use of HCPCS Modifier - CG                                                    (Rev. 4513, Issued: 02-04-2020, Effective: 01-01- 2020, Implementation: 01-06-2020)  Effective January 1, 2019, the modifier CG,  Policy criteria applied, can be reported with certain device-intensive procedures to reflect situations in which a device was not used during the device- intensive procedure.   This modifier would be reported on the UB04 form (CMS Form 1450) for hospital outpatient device-intensive procedures.  Report ing 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)