NYS APG Modifiers
- Also available in Excel Format (XLS, 49KB) and Portable Document Format (PDF, 23KB, 1pg.)
Revised for October 1, 2013 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. |
GN | Services delivered under an outpatient speech-language pathology plan of care | OPWDD, DOH | 10/01/13 | 10/01/11 | 272 | Deny any code that groups to Speech (272) if either a GN, HN, or HO modifier is missing. Deny the second code if two of the same code have the same GN, HN, or HO modifier. |
GO | Services delivered under an outpatient Occupationel Therapy plan of care. | OPWDD, DOH | 10/01/13 | 10/01/11 | 270 | Deny any code that groups to OT (270) if either a GO, HN, or HO modifier is missing. Deny the second code if two of the same code have the same GO, HN, or HO modifier. |
GP | Services delivered under an outpatient Physical Therapy plan of care | OPWDD, DOH | 10/01/13 | 10/01/11 | 271 | Deny any code that groups to PT (271) if either a GP, HN, or HO modifier is missing. Deny the second code if two of the same code have the same GP, HN, or HO modifier. |
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) | No 3M action required. This modifier is used to signal to MCOs that they must pay the billing provider the applicable FFS APG reimbursment amount for the E&M code. This modifier is used for Managed Care ONLY. |
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. | |
UC | Observation 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. | |
UD | 340B Drug | DOH | 04/01/11 | All drug APGs (pricer does not check for APG) | 25% reduction in payment. |