evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
CA: Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission    In the CY 2003 OPPS final rule (67 FR 66799), we discussed the creation of the new HCPCS modifier CA to address situations where a procedure on the OPPS inpatient -only list must be performed to resuscitate or stabilize a patient (whose status is that of an  outpatient) with an emergent, life -threatening condition, and the patient dies before being admitted as an inpatient. HCPCS modifier CA is defined as a procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission. In section VI of Transmittal A 02129, issued on January 3, 2003, we instructed hospitals on the use of this modifier. Transmittal A -02-129 is available on the cms.gov website. For a complete description of the history of the policy and the development of the payment methodology for these services, refer to the CY 2004 OPPS final rule (68 FR 63467 through 63468), CY 2005 OPPS Final Rule (69 FR 65841), CY 2007 OPPS final rule (71 FR 68157 through 68158), and CY 2012 OPPS/ASC final rule (76 FR 74153 through 74154).   20.6.9 - Modifier  FB (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FB: Item provided without cost to provider, supplier, or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples)   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.
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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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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).
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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.
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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
(Medicare Claims Processing Manual)
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
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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    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 st ated 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 effective 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
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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 instanc e 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 P BDs 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 unde r 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
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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
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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
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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 inflati on rebate liability.