NYS APG Modifiers

Revised for January 1, 2015 Updates:

For more detailed information regarding the use of modifiers in APGs, please see section 2.6 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: References:
25 Distinct Service (Medical visit) All Agencies 12/01/08   All APGs Does not change APG logic Also used to bypass NCCI edits, if appropriate.  
27 Distinct Medical Visit         Turned off in APGs.  
50 Bilateral Procedures All Agencies 12/01/08   All APGs First code is paid 100%, second code has a 50% reduction in payment.  
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. OMH APG Payment Modifiers
AG Primary Physician OMH, OASAS 10/01/10   315, 316, 317, 318, 323 20% increase for 318; 45% increase for all others. OMH APG Payment Modifiers
FB Obtained by Provider at No Cost OMH, DOH 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. September - 2012 OMH APG Payment Modifiers
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.  
GO, GP, or GN Services delivered under an outpatient occupational therapy (GO) , physical therapy (GP), or speech-language pathology (GN) plan of care. OPWDD, DOH 10/01/13 10/01/11 270, 271, 272 Deny any procedure code that groups to OT (270), PT (271), or Speech (272) if one of the following modifiers is missing (GO, GP, or GN modifier). December - 2011 September - 2015
HN Bachelors Degree OPWDD 01/01/11   All mental hygiene APGs (pricer does not check for APG) 25% reduction in payment. Note: Needs to be included if applicable for OT, PT, or Speech claims in an OPWDD setting. Will deny claim if modifier Gx and HN or HO is not on the claim.  
HO Masters Degree OPWDD 01/01/11    
HE Mental Health Program OMH, DOH 04/01/13 04/01/13 Medical visits that represent Psychiatric Assessments (in DOH or OMH clinics) or Psychotropic Med Mgt (only in OMH clinics) This modifier is used to signal to MCOs that they must pay the billing provider the applicable FFS APG reimbursement amount for the E&M code. **This modifier is used for Managed Care ONLY.** January - 2011
HQ Group Setting DOH 07/01/11   451 50% reduction in payment.                      April - 2011 May - 2011
JW Drug amount discarded/not administered to any patient All Agencies 01/01/15 01/01/15 All paying drug APGs (pricer does not check for APG) For payable APG drug bands- Added to second line and no payment for line with modifier. For drugs on APG fee schedule- Added to the second line and payment for line with modifier made based on units provided. August - 2015
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. APG Information for OASAS Outpatient Chemical Dependence Programs
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. OMH APG Payment Modifiers
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. October - 2010 December - 2011 September - 2012
U4 Language Other Than English OMH 07/01/10   310, 312, 315–318, 321, 323, 426, 490 (10/01/10) 10% increase in payment. OMH APG Payment Modifiers
U5 Reduced Services OMH 01/01/11   315, 316, 317, 318, 323 30% reduction in payment for school-based group psychotherapy services. OMH APG Payment Modifiers
U6 Reimbursable Ancillaries for D&TCs DOH 07/01/11   81, 149, 211, 281-283, 286-303, 330-332, 390-412, 470-471, and 486 Provides reimbursement to a D&TC for rendering an ancillary service in-house, or has a service/payment agreement in place with a separate provider not seeking direct Medicaid reimbursement. June - 2011
UC Observation services provided in a distinct unit DOH 04/01/13   450 Pays 100% of the allowed weight when appended to Px code G0378. If modifier is not present, 80% is paid. May - 2013
UD 340B Drug DOH 04/01/11   All drug APGs (pricer does not check for APG) 25% reduction in payment. February - 2013 March - 2015 May - 2015 July - 2015
XE Separate Encounter All Agencies 01/01/15   All APGs The line will discount instead of consolidating. Also used to bypass NCCI edits, if appropriate.  
XS Separate Structure All Agencies 01/01/15   All APGs The line will discount instead of consolidating. Also used to bypass NCCI edits, if appropriate.  
XP Separate Practitioner All Agencies 01/01/15   All APGs The line will discount instead of consolidating. Also used to bypass NCCI edits, if appropriate.  
XU Unusual Non-Overlapping Service All Agencies 01/01/15   All APGs The line will discount instead of consolidating. Also used to bypass NCCI edits, if appropriate.