MPFS Indicator Descriptors

X
 

MPFS Descriptors

Indicators Descriptor
NOTE - # Service Performed in Facility Setting
NOTE - C Payment for Technical Component is Capped at OPPS Amount
PROCEDURE/MOD CPT/HCPCS code and Modifier (26, TC, 53)
PAR AMOUNT Participating Physician Fee
NON-PAR AMOUNT Non-Participating Physician Fee
LIMITING CHARGE Limiting Charge for Non-Participating Physician
EHR Limiting Charge** Limiting charge reduced based on the EHR negative adjustment program.
PQRS Limiting Charge*** Limiting charge reduced based on the PQRS negative adjustment program.
EHR + PQRS Limiting Charge**** Limiting charge reduced for EPs that are subject to both EHR and PQRS negative adjustment programs.

 

Indicator List Descriptors

Indicators Descriptor
PROC CPT/HCPCS code
MOD Modifier (26, TC, 53)
S Status of CPT/HCPCS Code
GLB Global Surgery Package Days
Pre-op Preoperative Percentage (Modifier 54) - Percentage (in decimal format) for preoperative portion of the global package. For example, 10 percent will be shown as 010000.
Intraop Intraoperative Percentage (Modifier 78) - Percentage (in decimal format) for intraoperative portion of the global package in the hospital. For example, 63 percent will be shown as 063000.
Postop Postoperative Percentage (Modifier 55) - Percentage (in decimal format) for postoperative portion of the global package that is provided in the office after discharge from the hospital. For example, 17 percent will be shown as 017000.
P/T Professional/Technical Component Rules (Modifiers 26 and TC)
M Multiple Surgery Rules (Modifier 51)
B Bilateral Surgery Rules (Modifier 50)
A Assistant Surgery Rules (Modifier 80)
C Co-Surgeon Rules (Modifier 62)
T Team Surgeon Rules (Modifier 66)
ICI Imaging Cap Indicator
PSDP Physician Supervision of Diagnostic Procedures
ENDO BASE Endoscopy Base Code

 

S - Status

Indicators Descriptor
Astatus Active code. These codes are separately paid under the physician fee schedule if covered. There will be RVUs and payment amounts for codes with this status. The presence of an "A" indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy.
Bstatus Bundled code. Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amounts for these codes and no separate payment is ever made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a beneficiary).
Cstatus Carriers/MACs priced code. Carriers/MACS will establish RVUs and payment amounts for these services, generally on an individual case-by-case basis following review of documentation such as an operative report.
Estatus 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.
Istatus Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. (Code NOT subject to a 90 day grace period.)
Mstatus Measurement codes, used for reporting purposes only.
Nstatus Non-covered service.
Pstatus Bundled/excluded codes. There are no RVUs and no payment amounts for these services. No separate payment is made for them under the fee schedule. If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident (an example is an elastic bandage furnished by a physician incident to a physician service). If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (for example, colostomy supplies) and is paid under the other payment provision of the Act.
Qstatus Therapy functional information code. Used for required reporting purposes only. This indicator is no longer effective beginning with the 2020 fee schedule as of January 1, 2020.
Rstatus Restricted coverage. Special coverage instructions apply.
Tstatus Paid as only service. These codes are paid only if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made.
Xstatus Statutory exclusion. These codes represent an item or service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No RVUs or payment amounts are shown for these codes and no payment may be made under the physician fee schedule. (Examples are ambulances services and clinical diagnostic laboratory services.)

 

GLB - Global Surgery Package Days

Indicators Descriptor
000Global Surgery Package Days 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.
010Global Surgery Package Days 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.
090Global Surgery Package Days Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule payment amount.
MMMGlobal Surgery Package Days Maternity codes; usual global period does not apply.
XXXGlobal Surgery Package Days Global concept does not apply.
YYYGlobal Surgery Package Days MAC determines whether global concept applies and establishes postoperative period, if appropriate, at time of pricing.
ZZZGlobal Surgery Package Days Code related to another service and is always included in global period of other service. (Note: Physician work is associated with intra-service time and in some instances post service time.)

 

P/T - Professional/Technical Component (Modifiers 26 and TC)

Indicators Descriptor
0Professional/Technical Component (Modifiers 26 and TC) 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 and TC cannot be used with these codes. The total Relative Value Units (RVUs) include values for physician work, practice expense, and malpractice expense. There are some codes with no work RVUs.
1Professional/Technical Component (Modifiers 26 and TC) Diagnostic tests or radiology services. This indicator identifies codes that describe diagnostic tests (for example, pulmonary function tests or therapeutic radiology procedures such as radiation therapy). These codes generally have both a professional and technical component. Modifiers -26 and TC can be used with these codes. The total RVUs for codes reported with a -26 modifier include values for physician work, practice expense, and malpractice expense. The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only. The total RVUs for codes reported without a modifier equals the sum of RVUs for both the professional and technical component.
2Professional/Technical Component (Modifiers 26 and TC) 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. An example of a professional component only code is 93010, Electrocardiogram; interpretation and report.

Modifiers -26 and TC cannot be used with these codes. The total RVUs for professional component only codes include values for physician work, practice expense, and malpractice expense.
3Professional/Technical Component (Modifiers 26 and TC) Technical component only codes. This indicator identifies standalone codes that describe the technical component (such as staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic tests only. An example of a technical component code is 93005, Electrocardiogram, tracing only, without interpretation and report. 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 these codes. The total RVUs for technical component only codes include values for practice expense and malpractice expense only.
4Professional/Technical Component (Modifiers 26 and TC) Global test only codes. This indicator identifies stand alone codes for which there are associated codes that describe: a) the professional component of the test only and b) the technical component of the test only. Modifiers -26 and TC cannot be used with these codes. The total RVUs for global procedure only codes include values for physician work, practice expense, and malpractice expense. The total RVUs for global procedure only codes equals the sum of the total RVUs for the professional and technical components only codes combined.
5Professional/Technical Component (Modifiers 26 and TC) 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 or her direct supervision. Payment may not be made by carriers/MACs 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.
6Professional/Technical Component (Modifiers 26 and TC) 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. The total RVUs for laboratory physician interpretation codes include values for physician, work, practice expense, and malpractice expense.
7Professional/Technical Component (Modifiers 26 and TC) Private practice therapist's service. Payment may not be made if the service is provided to either a beneficiary in a hospital outpatient department or to an inpatient of the hospital by a physical therapist, occupational therapist, or speech-language pathologist in private practice.
8Professional/Technical Component (Modifiers 26 and TC) Physician interpretation codes. Identifies PC of clinical laboratory codes for which separate payment may be made only if physician interprets an abnormal smear for hospital inpatient. Applies only to code 85060. No TC billing is recognized because payment for underlying clinical laboratory test is made to hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. Physician interpretation is paid through clinical laboratory fee schedule payment for clinical laboratory test.
9Professional/Technical Component (Modifiers 26 and TC) Concept of a professional (26)/technical (TC) component does not apply.

 

M - Multiple Surgery (Modifier 51)

Indicators Descriptor
0Multiple Surgery (Modifier 51) No payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure, base payment on the lower of: (a) the actual charge or (b) the fee schedule amount for the procedure.
1Multiple Surgery (Modifier 51) Standard payment adjustment rules in effect before January 1, 1996, for multiple procedures apply. In 1996 MPFSDB, this indicator only applies to codes with procedure status of "D." If procedure is reported on same day as another procedure with indicator of 1, 2, or 3, rank procedures by fee schedule amount and apply appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report). Base payment on the lower of: (a) actual charge or (b) fee schedule amount reduced by appropriate percentage.
2Multiple Surgery (Modifier 51) Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, carriers/MACs rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report).  MACs base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
3Multiple Surgery (Modifier 51) Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (that is, another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in field 31G of the Form CMS-1500 or its electronic equivalent claim. The multiple endoscopy rules apply to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, the base procedure is not separately paid. Payment for the base procedure is included in the payment for the other endoscopy.
4Multiple Surgery (Modifier 51) Diagnostic imaging services subject to MPPR methodology. TC of diagnostic imaging services subject to a 50 percent reduction of the second and subsequent imaging services furnished by the same physician (or by multiple physicians in the same group practice, for example, same group National Provider Identifier [NPI]) to the same beneficiary on the same day, effective for services July 1, 2010, and after. PC of diagnostic imaging services are subject to a 25 percent payment reduction of the second and subsequent imaging services effective January 1, 2012.
5Multiple Surgery (Modifier 51) Selected therapy services subject to MPPR methodology. Subject to 20 percent of the practice expense component for certain therapy services furnished in office or other non-institutional settings, and 25 percent 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 percent 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).
6Multiple Surgery (Modifier 51) Diagnostic cardiovascular services subject to the MPPR methodology. Full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, that is, same group National Provider Identifier [NPI]) to the same beneficiary on the same day (effective for services January 1, 2013, and after).
7Multiple Surgery (Modifier 51) Diagnostic ophthalmology services subject to the MPPR methodology. Full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, that is, same group NPI) to the same beneficiary on the same day (effective for services January 1, 2013, and after).
9Multiple Surgery (Modifier 51) Multiple surgery concept does not apply.

 

B - Bilateral Surgery (Modifier 50)

Indicators Descriptor
0Bilateral Surgery (Modifier 50) 150 percent payment adjustment for bilateral procedures does not apply. If a procedure is reported with modifier -50 or with modifiers RT and LT, Medicare bases payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100.

Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The bilateral adjustment is inappropriate for codes in this category because of (a) physiology or anatomy or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.
1Bilateral Surgery (Modifier 50) 150 percent payment adjustment for bilateral procedures applies. If a code is billed with the bilateral modifier or is reported twice on the same day by any other means (such as with RT and LT modifiers or with a 2 in the units field), payment is based for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code.

If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, the bilateral adjustment is applied before applying any applicable multiple procedure rules.
2Bilateral Surgery (Modifier 50) 150 percent payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If a procedure is reported with modifier -50 or is reported twice on the same day by any other means (such as with RT and LT modifiers with a 2 in the units field), payment is based for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100.

Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The RVUs are based on a bilateral procedure because: (a) the code descriptor specifically states that the procedure is bilateral; (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or (c) the procedure is usually performed as a bilateral procedure.
3Bilateral Surgery (Modifier 50) The usual payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (such as with RT and LT modifiers or with a 2 in the units field), Medicare bases payment for each side or organ or site of a paired organ on the lower of: (a) the actual charge for each side or (b) 100 percent of the fee schedule amount for each side. If procedure is reported as a bilateral procedure and with other procedure codes on the same day, the fee schedule amount for a bilateral procedure is determined before applying any applicable multiple procedure rules.

Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.
9Bilateral Surgery (Modifier 50) Concept does not apply.

 

A - Assistant Surgery (Modifier 80)

Indicators Descriptor
0Assistant Surgery (Modifier 80) Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
1Assistant Surgery (Modifier 80) Statutory payment restriction for assistants at surgery applies to this procedure. Assistant surgeon may not be paid.
2Assistant Surgery (Modifier 80) Payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid.
9Assistant Surgery (Modifier 80) Assistant surgeon concept does not apply.

 

C - Co-Surgeon (Modifier 62)

Indicators Descriptor
0Co-Surgeon (Modifier 62) Co-surgeon not permitted for this procedure.
1Co-Surgeon (Modifier 62) Co-surgeons could be paid. Supporting documentation is required to establish medical necessity of two surgeons for the procedure.
2Co-Surgeon (Modifier 62) Co-surgeons permitted. No documentation is required if two specialty requirements are met.
9Co-Surgeon (Modifier 62) Co-surgeon concept does not apply.

 

T - Team Surgeon (Modifier 66)

Indicators Descriptor
0Team Surgeon (Modifier 66) Team surgeons not permitted for this procedure.
1Team Surgeon (Modifier 66) Team surgeons could be paid. Supporting documentation is required to establish medical necessity of a team; paid by report.
2Team Surgeon (Modifier 66) Team surgeons permitted; pay by report.
9Team Surgeon (Modifier 66) Team surgeon concept does not apply.

 

ICI - Imaging Cap Indicator

Indicators Descriptor
1Imaging Cap Indicator Subject to OPPS payment cap determination.
9Imaging Cap Indicator Not subject to OPPS payment cap determination.

 

PSDP - Physician Supervision of Diagnostic Procedures

Indicators Descriptor
01Physician Supervision of Diagnostic Procedures Procedure must be performed under general supervision of a physician.
02Physician Supervision of Diagnostic Procedures Procedure must be performed under direct supervision of a physician.
03Physician Supervision of Diagnostic Procedures Procedure must be performed under personal supervision of a physician.
04Physician Supervision of Diagnostic Procedures Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist. Otherwise the procedure must be performed under the general supervision of a physician.
05Physician Supervision of Diagnostic Procedures 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.
06Physician Supervision of Diagnostic Procedures Procedure must be performed by a physician or a physical therapist (PT) who is certified by American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide procedure under State law. Procedure may also be performed by a PT with ABPTS certification without physician supervision.
21Physician Supervision of Diagnostic Procedures Procedure may be performed by a technician with certification under general supervision of a physician.  Otherwise the procedure must be performed under direct supervision of a physician. Procedure may also be performed by a PT with ABPTS certification without physician supervision.
22Physician Supervision of Diagnostic Procedures May be performed by a technician with on-line real-time contact with physician.
66Physician Supervision of Diagnostic Procedures May be performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.
6APhysician Supervision of Diagnostic Procedures Supervision standards for level 66 apply; in addition, PT with ABPTS certification may supervise another PT, but only PT with ABPTS certification may bill.
77Physician Supervision of Diagnostic Procedures 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).
7APhysician Supervision of Diagnostic Procedures Supervision standards for level 77 apply; in addition, PT with ABPTS certification may supervise another PT, but only PT with ABPTS certification may bill.
9Physician Supervision of Diagnostic Procedures Concept does not apply.

 

Diagnostic Imaging Family Indicator

*For services effective January 1, 2011, and after, family indicators 01 - 11 will not be populated.

Indicators Descriptor
01*Diagnostic Imaging Family Indicator Family 1 Ultrasound (Chest/Abdomen/Pelvis - Non Obstetrical)
02*Diagnostic Imaging Family Indicator Family 2 CT and CTA (Chest/Thorax/Abd/Pelvis)
03*Diagnostic Imaging Family Indicator Family 3 CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck)
04*Diagnostic Imaging Family Indicator Family 4 MRI and MRA (Chest/Abd/Pelvis)
05*Diagnostic Imaging Family Indicator Family 5 MRI and MRA (Head/Brain/Neck)
06*Diagnostic Imaging Family Indicator Family 6 MRI and MRA (Spine)
07*Diagnostic Imaging Family Indicator Family 7 CT (Spine)
08*Diagnostic Imaging Family Indicator Family 8 MRI and MRA (Lower Extremities)
09*Diagnostic Imaging Family Indicator Family 9 CT and CTA (Lower Extremities)
10*Diagnostic Imaging Family Indicator Family 10 MR and MRI (Upper Extremities and Joints)
11*Diagnostic Imaging Family Indicator Family 11 CT and CTA (Upper Extremities)
88Diagnostic Imaging Family Indicator Subject to the reduction of the TC diagnostic imaging (effective for services January 1, 2011, and after). Subject to the reduction of the PC diagnostic imaging (effective for services January 1, 2012, and after).
99Diagnostic Imaging Family Indicator Concept Does Not Apply.

 

 

Last Updated Mon, 11 Nov 2019 08:37:49 +0000