evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Modifiers - 73 and - 74 are only used to indicate discontinued procedures for which anesthesia is planned or provided. B. Effect on Payment  Procedures that are discontinued after the patient has been prepared for the p rocedure and taken to the procedure room but before anesthesia is provided will be paid at 50 percent of the full OPPS payment amount. Modifier - 73 is used for these procedures. As of January 1, 2016, for device -intensive procedures that append modifier - 73, we will reduce the APC payment amount for the discontinued device -intensive procedure, by 100 percent of the device offset amount prior to applying the additional payment adjustments that apply when the procedure is discontinued as modified by means of a final rule with comment period and published in the November 13, 2015 Federal Register (80 FR 70424). Beginning January 1, 2017, device -intensive procedures are defined as those procedures requiring the insertion of an implantable device, that also hav e a HCPCS - level device offset greater than 40 percent. From January 1, 2016 through December 31, 2016 device -intensive procedures were defined as those procedures that involve implantable devices that are assigned to a device- intensive APC (defined as those APCs with a device offset greater than 40 percent). Beginning January 1, 2019, device -intensive procedures are defined as procedures that involve the surgical implantation or insertion of an implantable device that is assigned a CPT or HCPCS code (including single -use devices) and has a device offset amount that exceeds 30 percent of the procedures mean cost.  Procedures that are discontinued, partially reduced or cancelled after the procedure has been initiated and/or the patient has received anesthesia will be paid at the full OPPS payment amount. Modifier - 74 is used for these procedures.  Procedures for which anesthesia is not planned that are discontinued, partially reduced or cancelled after the patient is prepared and taken to the room where the pr ocedure is to be performed will be paid at 50 percent of the full OPPS payment amount. Modifier - 52 is used for these procedures.  20.6.5 - Modifiers for Repeat Procedures  (Rev. 1, 10- 03-03)  Two repeat procedure modifiers are applicable for hospital use:    Modifier - 76 is used to indicate that the same physician repeated a procedure or service in a separate operative session on the same day.
(Medicare Claims Processing Manual)
Two repeat procedure modifiers are applicable for hospital use:    Modifier - 76 is used to indicate that the same physician repeated a procedure or service in a separate operative session on the same day.    Modifier - 77 is used to indicate that another physician repeated a procedure or service in a separate operative session on the same day.    If there is a question regarding who the ordering physician was and whether or not the same physician ordered the second procedure, the code selected is based on whether or not the physician performing the procedure is the same.   The procedure must be the same procedure.  It is listed once and then listed again with the appropriate modifier.   20.6.6 - Modifiers for Radiology Services  (Rev. 1599, Issued: 09- 19-08, Effective: 10- 01-08, Implementation: 10- 06-08)  Modifiers - 52 (Reduce d Services), -59, -76, and - 77, and the Level II modifiers apply to radiology services.   When a radiology procedure is reduced, the correct reporting is to code to the extent of the procedure performed.  If no HCPCS code exists for the service that has bee n completed, report the intended HCPCS code with modifier - 52 appended.   EXAMPLE:  CPT code 71020 (Radiologic examination, chest, two views, frontal and lateral) is ordered.  Only one frontal view is performed.  CPT code 71010 (Radiologic examination, ches t: single view, frontal) is reported.  The service is not reported as CPT code 71020- 52.  20.6.7 - CA Modifier  (Rev. 1, 10- 03-03)  Definition:   Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission.  20.6.8 - HCPCS Level II Modifiers (Rev. 1, 10- 03-03)  Generally, these codes are required to add specificity to the reporting of procedures performed on eyelids, fingers, toes, and arteries.  They may be appended to CPT codes.  If more than one  level II modifier applies, the HCPCS code is repeated on another line with the appropriate level II modifier:   EXAMPLE:  Code 26010 (drainage of finger abscess; simple) done on the left thumb and second finger would be coded:
(Medicare Claims Processing Manual)
EXAMPLE:  Code 26010 (drainage of finger abscess; simple) done on the left thumb and second finger would be coded:   26010FA  26010F1  The Level II  modifiers apply whether Medicare is the primary or secondary payer.   20.6.9 - Use of HCPCS Modifier -FB  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Effective January 1, 2007, the definition of modifier - FB is  Item Provid ed Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples) .  See the Medicare Claims Processing Manual, Pub 100- 04, Chapter 4, 61.3 for instructions regarding charges for items billed with the -FB modifier.    The OPPS hospitals must report modifier - FB on the same line as the procedure code (not the device code) for a service that requires a device for which neither the hospital, nor the beneficiary, is liable to the manufacturer.  Hospitals must report modifie r -FB on the same line as the procedure code for a service that requires a device when the manufacturer gives credit for a device being replaced with a more costly device.   20.6.10 - Use of HCPCS Modifier -FC  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Effective January 1, 2008, the definition of modifier - FC is  Partial credit received for replaced device.   See the Medicare Claims Processing Manual, Pub 100 -04, Chapter 4, 61.3 for instructions regarding charges for items  billed with modifier - FC. OPPS hospitals must report modifier - FC for cases in which the hospital receives 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 append modifier - FC to the procedure code (not the device code) that reports the services provided to replace the device.   20.6.11 - Use of HCPCS Modifier   PO (Rev. 4204, Issued: 01- 17-19, Effective: 01- 01-19, Implementation: 01- 07-19)
(Medicare Claims Processing Manual)
20.6.11 - Use of HCPCS Modifier   PO (Rev. 4204, Issued: 01- 17-19, Effective: 01- 01-19, Implementation: 01- 07-19)   Effective January 1, 2015, the definition of modifier - PO is  Services, procedures, and/or surgeries furnished at excepted off- campus provider -based outpatient departments.  This modifier is to 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.   Reporting of this modifier i s voluntary for CY 2015; reporting of this modifier is required beginning January 1, 2016. We note that beginning in CY 2019 we are finalizing a policy to pay for clinic visits (G0463) billed at excepted off -campus provider based departments (departments t hat bill modifier PO on their claim lines) at the PFS -equivalent amount.  The PFS -equivalent amount paid to nonexcepted off -campus PBDs is 40 percent of OPPS payment (that is, 60 percent less than the OPPS rate) for CY 2019. We are phasing this policy in  over a two year period. Specifically, half of the total 60- percent payment reduction, a 30- percent reduction, will apply in CY 2019. In other words, these departments will be 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 service in CY 2019. 20.6.12 - Use of HCPCS Modifier   PN (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  A. General
(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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)  Prior to October 1, 2006, the C series of HCPCS codes were used exclusively by hospitals subject to OPPS to identify items that may have qualified for transitional pass through payment under OPPS or items or services for which an appropriate HCPCS code did not exist for the purposes of implementing the OPPS.  The C -codes could not be used to bill services payable under other payment systems.  CMS realized that these C -codes evolved and also target services that are uniquely hospital services that may be provided by an OPPS provider, other providers, or be paid under other payment systems.  Effective October 1, 2006, the following non-OPPS providers may elect to bill using the C-codes or an appropriate CPT code on Types of Bill (TOBs) 12X, 13X, or 85X:   Critical Access Hospitals (CAHs);  Indian Health Service Hospitals (IHS);   Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and  Maryland waiver hospitals.  The OPPS providers shall continue to receive pass -through payment on items or services that qualify for pass through payment. Non-OPPS providers are not eligible for pass through payments.  The C -codes shall be replaced with permanent codes.  Whenever a permanent code is established to replace a temp orary code, the temporary code is deleted and cross-referenced to the new permanent code.  Upon deletion of a temporary code, providers shall bill using the new permanent code.  Providers are encouraged to access the CMS Web site to view the quarterly HCPC S Code updates.  The URL to view the quarterly updates is http://www.cms.hhs.gov/HCPCSReleaseCodeSets/.
(Medicare Claims Processing Manual)
The billing of C- codes by Method I and Method II Critical Access Hospitals (CAHs) is limited to the billing for facility (technical) services.  The C -codes shall not be billed by Method II CAHs for professional services with revenue codes 96X, 97X, or 98X.   30 - OPPS Coinsurance  (Rev. 2141, Issued: 01- 24-11, Effective: 01- 01-11, Implementation:  01-03-11)  OPPS freezes coinsurance for outpatient hospital at 20 percent of the national median charge for the services within each APC (wage adjusted for the providers geographic area), but coinsurance for an APC cannot be less than 20 percent of the A PC payment rate.  As the total payment to the provider increases each year based on market basket updates, the present or frozen coinsurance amount will become a smaller portion of the total payment until coinsurance represents 20 percent of the total paym ent.  Once coinsurance becomes 20 percent of the payment amount, the annual updates will also increase coinsurance so that it continues to account for 20 percent of the total payment.  As previously stated, the wage -adjusted coinsurance for a service under  OPPS cannot exceed the inpatient deductible amount.  Section 111 of BIPA accelerates the reduction of beneficiary copayment amounts by providing that for services furnished on or after April 1, 2001, and before January 1, 2002, the national unadjusted cop ayment amount for any ambulatory payment classification (APC) group cannot exceed 57 percent of the APC payment rate.  The statute makes further reductions in future years so that national unadjusted copayment amounts cannot exceed 55 percent of the APC rate in 2002 and 2003, 50 percent in 2004, 45 percent in 2005, and 40 percent in 2006 and later years.   The annual update of the OPPS Pricer includes updated copayment amounts.  For screening colonoscopies and screening flexible sigmoidoscopies, the coinsurance amount is 25 percent of the payment rate, prior to January 1, 2011. Coinsurance does not apply to screening colonoscopies, screening sigmoidoscopies, and other specified services furnished on or after January 1, 2011.