CMS Pub. 100-04, ch. 23, § 50.6

When a Medicare beneficiary elects hospice services, hospices must complete the data elements

identified below for the Uniform (Institutional Provider) Bill (Form CMS-1450) or its electronic

equivalent, which is a Notice of Election (NOE).

The information on the Physician Fee Schedule Payment Policy Indicator file record layout is used for

processing Method II CAH professional services with revenue codes 96X, 97X or 98X.

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

File Year

This field displays the effective year of

the file.

4 Pic x(4) 1-4

HCPCS Code

This field represents the procedure

code. Each Current Procedural

Terminology (CPT) code and alpha-numeric HCPCS codes that are currently

returned on the MPFS supplemental file

will be included when the MPFS Status

Indicator is A, C, T, and some with

R. The standard sort for this field is

blanks, alpha, and numeric in ascending

order.

5 Pic x(5) 5-9

Modifier

For diagnostic tests, a blank in this field

denotes the global service and the

following modifiers identify the

components:

26 = Professional component; and

TC = Technical component.

For services other than those with a

professional and/or technical component,

a blank will appear in this field with one

exception: the presence of CPT modifier -

53 which indicates that separate Relative

Value Units (RVUs) and a fee schedule

amount have been established for

procedures which the physician

terminated before completion. This

modifier is used only with colonoscopy

code 45378 and screening colonoscopy

codes G0105 and G0121. Any other

codes billed with modifier -53 are subject

to medical review and priced by

individual consideration.

Modifier-53 = Discontinued Procedure -

Under certain circumstances, the

physician may elect to terminate a

surgical or diagnostic procedure. Due to

extenuating circumstances, or those that

2 Pic x(2) 10-11

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

threaten the well being of the patient, it

may be necessary to indicate that a

surgical or diagnostic procedure was

started but discontinued.

Code Status

This 1 position field provides the status of

each code under the full fee schedule.

Each status code is explained in Pub. 100-

04, Chapter 23, §30.2.2.

1 Pic x(1) 12

Global Surgery

This field provides the postoperative time

frames that apply to payment for each

surgical procedure or another indicator

that describes the applicability of the

global concept to the service.

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.

3 Pic x(3) 13-15

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

XXX = Global concept does not apply.

YYY = A/B MAC (A) 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. (NOTE:

Physician work is associated with intra-service time and in some instances the

post service time.)

Preoperative Percentage (Modifier 56)

This field contains the percentage (shown

in decimal format) for the preoperative

portion of the global package. For

example, 10 percent will be shown as

010000. The total of the preoperative

percentage, intraoperative percentage, and

the postoperative percentage fields will

usually equal one. Any variance is slight

and results from rounding.

6 Pic 9v9(5) 16-21

Intraoperative Percentage (Modifier

54)

This field contains the percentage (shown

in decimal format) for the intraoperative

portion of the global package including

postoperative work in the hospital. For

example, 63 percent will be shown as

063000. The total of the preoperative

percentage, intraoperative percentage, and

the postoperative percentage fields will

usually equal one. Any variance is slight

and results from rounding.

6 Pic 9v9(5) 22-27

Postoperative Percentage (Modifier 55)

This field contains the percentage (shown

in decimal format) for the 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. The

6 Pic 9v9(5) 28-33

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

total of the preoperative percentage,

intraoperative percentage, and the

postoperative percentage fields will

usually equal one. Any variance is slight

and results from rounding.

Professional Component

(PC)/Technical Component (TC)

Indicator

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. The total

Relative Value Units (RVUs) include

values for physician work, practice

expense and malpractice expense. There

are some codes with no work RVUs.

1 = Diagnostic tests or radiology services:

This indicator identifies codes that

describe diagnostic tests, e.g., pulmonary

function tests, or therapeutic radiology

procedures, e.g., 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.

2 = Professional component only codes:

1 Pic x(1) 34

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

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.

3 = Technical component only codes:

This indicator identifies stand alone codes

that describe the technical component

(i.e., 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.

4 = 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,

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

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.

5 = Incident to Codes: This indicator

identifies codes that describe services

covered incident to a physicians 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 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. The total

RVUs for laboratory physician

interpretation codes include values for

physician work, practice expense and

malpractice expense.

7 = Physical therapy service: Payment

may not be made if the service is

provided to either a hospital outpatient or

inpatient by an independently practicing

physical or occupational therapist.

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

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

the underlying clinical laboratory test is

made to the hospital, generally through

the PPS rate.

No payment is recognized for code 85060

furnished to hospital outpatients or non-hospital patients. The physician

interpretation is paid through the clinical

laboratory fee schedule payment for the

clinical laboratory test.

9 = Concept of a professional/technical

component does not apply

Multiple Procedure (Modifier 51)

Indicator indicates which payment

adjustment rule for multiple procedures

applies to the service.

0 = No payment adjustment rules for

multiple procedures apply. If the

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.

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

percent, 50 percent, 25 percent, 25

percent, 25 percent, and by report). Base

payment on the lower of: (a) the actual

charge or (b) the fee schedule amount

reduced by the appropriate percentage.

2 = 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, rank the procedures by fee

schedule amount and apply the

appropriate reduction to this code (100

1 Pic (x)1 35

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

percent, 50 percent, 50 percent, 50

percent, 50 percent, and by report). Base

payment on the lower of: (a) the actual

charge or (b) the fee schedule amount

reduced by the appropriate percentage.

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). The base

procedure for each code with this

indicator is identified in the endoscopic

base code field.

Apply the multiple endoscopy rules 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, do not pay

separately for the base procedure.

Payment for the base procedure is

included in the payment for the other

endoscopy.

4 = Subject to 25% reduction of the TC

diagnostic imaging (effective for services

January 1, 2006 through June 30, 2010).

Subject to 50% reduction of the TC

diagnostic imaging (effective for services

July 1, 2010 and after). Subject to 25%

reduction of the PC of diagnostic imaging

(effective for services January 1, 2012

through December 31, 2016). Subject to

5% reduction of the PC of diagnostic

imaging (effective for services January 1,

2017 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%

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

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.

Codes with RVUs equal to zero are not

included in the payment indicator file.

These codes may have multiple procedure

indicators not shown. See note below this

table for instructions on these codes.

Bilateral Surgery Indicator (Modifier

50)

This field provides an indicator for

services subject to a payment adjustment.

0 = 150 percent payment adjustment for

bilateral procedures does not apply.

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.

1 Pic (x)1 36

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

1 = 150 percent payment adjustment for

bilateral procedures applies. If code is

billed with the bilateral modifier base

payment 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, apply the bilateral

adjustment before applying any

applicable multiple procedure rules.

2 = 150 percent payment adjustment for

bilateral procedure does not apply. RVUs

are already based on the procedure being

performed as a bilateral procedure.

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.

3 = The usual payment adjustment for

bilateral procedures does not apply.

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. If a procedure is billed with

the 50 modifier, base payment on the

lesser of the total actual charges for each

side or 100% of the fee schedule amount

for each side.

9 = Concept does not apply.

Assistant at Surgery (Modifiers AS, 80, 1 Pic (x)1 37

FIELD NAME & DESCRIPTION LENGTH &

PIC

Position

81 and 82)

This field provides an indicator for

services where an assistant at surgery

may be paid:

0 = Payment restriction for assistants at

surgery applies 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.

Co-Surgeons (Modifier 62)

This field provides an indicator for

services for which two surgeons, each in

a different specialty, may be paid.

0 = Co-surgeons not permitted for this

procedure.

1 = Co-surgeons could be paid;

supporting documentation required to

establish 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.

1 Pic (x)1 38

Team Surgeons (Modifier 66) 1 Pic (x)1 39

Multiple procedure indicator

5 is included in this file;

however, the indicator

represents the therapy

multiple procedure payment

reduction which never applies

to professional service

revenue codes on CAH

outpatient claims. Multiple

procedure indicators 6 and 7

are included in this file,

however, since in these cases

the reduction only applies to

technical component services,

they will not affect the cost-based payment on CAH

claims. On CAH claims,

technical components are

paid on a cost basis and so are

not subject to the reductions.

There may be cases when

A/B MACs (A) must

manually load a HCPCS code

that is contractor priced

which has a multiple

procedure indicator that is not

on the payment indicator file.

In these cases, the MAC

enters a multiple procedure

indicator of 0.