APGs

NYS APG Modifiers

Revised for October 1, 2012 Updates:

For more detailed information regarding the use of modifiers in APGs, please see section 2.5 of the APG Provider Manual

Modifier Modifier Description State Agencies Using Modifier Effective Date Date Added to List APGs Affected by Modifier Application of Modifer
25 Distinct Service (medical visit) All Agencies 12/01/08 All APGs Does not change APG logic; can be used to bypass certain NCCI edits if appropriate.
27 Distinct Medical Visit 491 (regroups to 449) Turned off in APGs.
50 Bilateral Procedures All Agencies 12/01/08 All APGs First code paid 100%, second paid 50%.
52 Reduced Services All Agencies 12/01/08 All APGs 50% reduction in payment.
59 Separate Procedures or Distinct Procedural Services All Agencies 12/01/08 All APGs The line will discount instead of consolidating. Also used to bypass NCCI edits, if appropriate.
73 Terminated Procedure All Agencies 12/01/08 All APGs 50% reduction in payment.
AF Specialty Physician OMH, OASAS 10/01/10 315, 316, 317, 318, 323 20% increase for 318; 45% increase for all others.
AG Primary Physician OMH, OASAS 10/01/10 315, 316, 317, 318, 323 20% increase for 318; 45% increase for all others.
FB Obtained by Provider at No Cost OMH 10/01/10 10/01/11 414, 415, 416, all drug APGs (category 24) Pays $13.23 for line based on proxy weight and statewide base rate. Retro to Oct 2010. Don't code admin/inj code.
G1 - G6 URR Level for Dialysis DOH 10/01/11 10/01/11 169 (is reassigned to 168) Causes APG 169 to be reassigned to APG 168. G6 is not the URR level but indicates that less than 6 session were received during a month, but G6 should still cause APG 169 to be reassigned to APG 168.
HN Bachelors Degree OPWDD 01/01/11 All mental hygiene APGs (pricer does not check for APG) 25% reduction in payment.
HO Masters Degree OPWDD 01/01/11 All mental hygiene APGs (pricer does not check for APG) 25% reduction in payment.
HQ Group Setting DOH 07/01/11 451 50% reduction in payment.
KP First drug of a multiple drug unit use formulation OASAS 10/01/12 10/01/12 322 Doubles payment for first H0020 on a claim.
PA Surgical procedure on wrong body part DOH 07/01/12 07/01/12 All No payment for line with modifier.
PB Surgical procedure on wrong patient DOH 07/01/12 07/01/12 All No payment for line with modifier.
PC Wrong surgery or procedure on patient DOH 07/01/12 07/01/12 All No payment for line with modifier.
SA Nurse Practitioner OMH, OASAS 10/01/10 315, 316, 317, 318, 323 20% increase for 318; 45% increase for all others.
SL State Supplied Vaccine (VFC program) DOH 12/01/08 10/01/11 414, 415, 416 Pays $17.85 for line based on proxy weight and statewide base rate. Retro to Dec 2008. Don't code admin/inj code.
U4 Language Other Than English OMH 07/01/10 310, 312, 315–318, 321, 323, 426, 490 (10/01/10) 10% increase in payment.
U5 Reduced Services OMH 01/01/11 315, 316, 317, 318, 323 30% reduction in payment - SBHC for OMH.
U6 Reimbursable Ancillary DOH 07/01/11 All ancillary APGs as defined by NYS Allows payment for ancillary APGs.
UD 340B Drug DOH 04/01/11 All drug APGs (pricer does not check for APG) 25% reduction in payment.

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