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Medicare Physician Fee Schedule Database Indicator File Descriptors

 

Category

Indicator

Indicator Description

S Status Indicators A Active code. These codes are separately paid under the physician fee schedule, if covered.
B Bundled code. Payment for covered services is always bundled into payment for other services not specified.
C Carrier-priced code. Carrier will establish the RVUs and payment amounts for these services, generally on a individual case basis following review of documentation such as an operative report.
D Deleted codes. These codes are deleted effective the beginning of the year.
E Excluded from physician fee schedule by regulation. These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation. NO RVUs or payment amounts are shown and no payment may be made under the fee schedule for these codes. Payment for them, when covered continues under reasonable charge procedures.
F Deleted/discontinued codes, not subject to 90 day grace period.
G Code is not valid for Medicare purposes. Providers are to bill for these services using other codes.
H Deleted modifier. This code has a TC and/or PC in 1999. For 2000 and later years , the TC/PC component shown for the code has been deleted and the deleted component is shown in the data base with the H status.
I Code is not valid for Medicare purposes. Medicare uses another code for the reporting of and payment for these services. (Code NOT subject to a 90 day grace period.)
J Anesthesia services (no RVU or payment amounts for anesthesia codes on the database, only used to facilitate the identification of anesthesia services.)
M Measurement codes, used for reporting purposes only
N Noncovered services.
P Bundled or excluded code. There are no RVUs for these services. No separate payment should be made for them under the physician fee schedule
Q Therapy functional information code, used for required reporting purposes only
R Restricted coverage. Special coverage instructions apply.
T Injections. There are RVUs for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.
X Exclusion by law. These codes represent an item or service that is not within the definition of “physician service” for physician fee schedule payment purposes. Services are still paid under Medicare Part B, examples are Ambulance or Clinical lab codes.
G Global Period 000 Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.
010 Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during this 10-day postoperative period generally not payable.
090 Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule payment amount.
MMM Maternity codes; usual global period does not apply.
XXX Global concept does not apply.
YYY Carrier determines whether global concept applies and establishes postoperative period, if appropriate, at time of pricing.
ZZZ Code related to another service and is always included in the global period of the other service.
Pre% Pre-operative % – Modifier 56 Indicates the percentage of the global allowable for the preoperative portion of the global package.
Intra% Intra-operative % – Modifier 54 Indicates the percentage of the global allowable for the intraoperative portion of the global package including postoperative work in the hospital.
Post% Post-operative % – Modifier 55 Indicates the percentage of the global allowable for the postoperative portion of the global package that is provided in the office after discharge from the hospital.
P Professional/Technical Component- Modifiers 26 and TC 0 Physician service codes. This indicator identifies codes that describe physician services. Examples include visits, consultations, and surgical procedures. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifiers 26 & TC cannot be used with these codes.
1 Diagnostic tests or radiology services. This indicator identifies codes that describe diagnostic tests. These codes generally have both a professional and technical component. Modifiers 26 and TC can be used with these codes.
2 Professional component only codes. This indicator identifies stand alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test only and another associated code that describes the global test. Modifiers 26 and TC cannot be used with this code.
3 Technical component only codes. This indicator identifies stand alone codes that describe the technical component of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic test only. It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used with this code.
4 Global test only codes. This indicator identifies stand alone codes that describe selected diagnostic tests for which there are associated codes that describe a) the professional component only and b) the technical component of the test only. Modifiers 26 and TC cannot be used with these codes.
5 Incident to codes. This indicator identifies codes that describe services covered incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his/her direct supervision. Payment may not be made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 26 and TC cannot be used with these codes.
6 Laboratory physician interpretation codes. This indicator identifies clinical laboratory codes for which separate payment for interpretations by laboratory physicians may be made. Actual performance of the tests is paid for under the lab fee schedule. Modifier TC cannot be used with these codes.
7 Private Practice therapist’s service. Payment may not be made if the service is provided to either a hospital outpatient or inpatient by a physical , occupational, or speech-language pathologist in private practice.
8 Physician interpretation codes. This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. This applies only to code 85060. No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate.
9 Concept of a professional/technical component does not apply.
M Multiple Surgery Modifier 51 0 No payment adjustment rules for multiple procedures apply. If procedure is reported on same day as another procedure, base payment on lower of a) the actual charge or b) the fee schedule amount for the procedure.
1 Standard payment adjustment rules in effect before January 1, 1996 for multiple procedures apply. In the 1996 MPFSDB, this indicator only applies to codes with procedure status of “D”. If a procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report).
2 Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50%, and by report).
3 Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).
4 Subject to 25% reduction of the TC diagnostic imaging (effective for services 1-1-2006 through June 30, 2010). Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1, 2010 and after).
5 Subject to 20% reduction of the practice expense component for certain therapy services furnished in office and other non-institutional settings, and 25% reduction of the practice expense component for certain therapy services furnished in institutional settings (effective for services January 1, 2011 and after). Subject to 50% reduction of the practice expense component for certain therapy services furnished in both institutional and non-institutional settings (effective for services April 1, 2013 and after).
6 Subject to 25% reduction of the TC diagnostic cardiovascular services (effective for services January 1, 2013 and after).
7 Subject to 20% reduction of the TC diagnostic ophthalmology services (effective for services January 1, 2013 and after).
9 Concept does not apply.
B Bilateral Surgery Modifier 50 0 150% payment adjustment for bilateral procedures does not apply. Bilateral is inappropriate for codes in this category because of (a) physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.
1 150% payment adjustment for bilateral procedures applies. Modifier 50 appropriate if procedure is performed bilaterally. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g. with RT and LT modifiers or with a 2 in the units field), allows 150% of usual amount.
2 150% payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure.
3 200% payment adjustment for bilateral procedures applies. Modifier 50 appropriate if performed bilaterally.
9 Concept does not apply.
A Assistant at Surgery Modifiers 80, 82, AS 0 Payment restrictions for assistants at surgery apply to this procedure unless supporting documentation is submitted to establish medical necessity.
1 Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.
2 Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.
9 Concept does not apply.
C Co-Surgeon Modifier 62 0 Co-surgeons not permitted for this procedure.
1 Co-surgeons could be paid; supporting documentation required to establish the medical necessity of two surgeons for the procedure.
2 Co-surgeons permitted; no documentation required if two specialty requirements are met.
9 Concept does not apply.
T Team Surgeons Modifier 66 0 Team surgeons not permitted for this procedure.
1 Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report.
2 Team surgeons permitted; pay by report.
9 Concept does not apply.
Physician Supervision of Diagnostic Procedures

 

This field is for use in post payment review.

 

01  

Procedure must be performed under the general supervision of a physician.

 

02 Procedure must be performed under the direct supervision of a physician
03 .

Procedure must be performed under the personal supervision of a physician.

 

04 Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist; otherwise must be performed under the general supervision of a physician.

 

05 Not subject to supervision when furnished personally by a qualified audiologist, physician or non physician practitioner. Direct supervision by a physician is required for those parts of the test that may be furnished by a qualified technician when appropriate to the circumstances of the test.

 

06 Procedure must be personally performed by a physician or a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiological clinical specialist and is permitted to provide the procedure under State law. Procedure may also be performed by a PT with ABPTS certification without physician supervision.

 

21 Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician. Procedure may also be performed by a PT with ABPTS certification without physician supervision.

 

22 May be performed by a technician with on-line real-time contact with physician.

 

66 May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.

 

6A Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.

 

77  

Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC & PC), or by a technician with

certification under general supervision of a physician (TC only; PC always physician).

 

7A Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.

 

09 Concept does not apply.

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