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2011 New modifiers and its usage


Modifier AY: Item/service not for ESRD treatment
Certain laboratory services and limited drugs and supplies will be subject to Part B consolidated billing and will no longer be separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility. Should these lab services, and limited drugs be provided to a beneficiary, but are not related to the treatment for ESRD, the claim lines must be submitted by the laboratory supplier or other provider with the new AY HCPCS modifier to allow for separate payment outside of ESRD PPS. ESRD facilities billing for any labs or drugs will be considered part of the bundled PPS payment unless billed with the HCPCS modifier AY.

Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM7064.pdf


When claims are received without the AY modifier for items and services that are not separately payable due to the ESRD PPS consolidated billing process, the claims will be returned with claim adjustment reason code (CARC) 109 (Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.), RARC N538 (A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.), and assign Group code CO.

Modifier AZ: Physician service in dental HPSA Long description: “Physician providing a service in a Dental Health Professional Shortage Area for the purpose of an Electronic Health Record Incentive payment.”
In order to allow EPs to report claims rendered in a dental HPSA when the zip code does not fully fall within the dental HPSA, CMS has developed a new EHR HPSA modifier AZ. It is effective for dates of service on and after January 1, 2011. The new modifier will not affect the payment or calculation of the FFS geographic quarterly HPSA bonus.

The Integrated Data Repository will be responsible for determining which EPs are due the EHR HPSA incentive payment increase and determining the amount of the payment.

Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM7035.pdf


Modifier CS: Gulf Oil 2010 Spill Related Long description: “Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean-up activities.”
CMS is requiring that every Medicare Fee-For-Service claim be specifically identified if it is for an item or service furnished to a Medicare beneficiary, where the provision of such item or service is related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico and/or circumstances related to such oil spill, including but not limited to subsequent clean-up activities.

Claims from physicians, other practitioners, and suppliers must be annotated with the modifier “CS” for each line item where the item or service is so related. Similarly, claims from institutional billers must be annotated with a condition code of “BP” when the entire claim is so related or with the “CS” modifier for each relevant line item when only certain line items are so related. The modifier and condition code are to be used for claims with dates of service on or after April 20, 2010.

The title of the BP condition code is “Gulf oil spill related” and its definition is as follows: “This code identifies claims where the provision of all services on the claim are related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico and/or circumstances related to such spill, including but not limited to subsequent clean-up activities.”

Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM7087.pdf


Modifier-PT - Colorectal Cancer screening test, converted to diagnostic test or other procedure

Modifier PT should be appended for the diagnostic procedure code that is reported instead of the screening colonoscopy or screening flexible sigmoidoscopy HCPCS code, or as a result of the barium enema when the screening test becomes a diagnostic service. This will prompt the claims processing system to waive the deductible for all surgical services on the same date of service as the diagnostic service. Modifier PT should be appended only if the planned screening service becomes a diagnostic service.

Reference:
http://www.cms.gov/MLNMattersArticles/downloads/MM7012.pdf


Other New modifiers w.e.f. Jan 1, 2011 and its short descriptions are as follows

DA Oral health assess, not dent
GU Liability waiver rout notice
GX Voluntary liability notice
NB Drug specific nebulizer

Also refer:


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