Pricing Modifiers

100.6 - Pricing Modifiers (Rev. 2487, Issued: 06-08-12, Effective: 01-01-11, Implementation: 06-19-12) PM A-03-033 Prior to January 1, 2011 Three pricing modifiers discretely identify the different payment situations for ESRD Automated Multi-Channel Chemistry (AMCC) tests. The physician that orders the tests is responsible for identifying the appropriate modifier when ordering the tests. The modifiers are in the following listing: • CD - AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable • CE - AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity • CF - AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable The ESRD clinical laboratory tests identified with modifiers “CD,” “CE,” or “CF” may not be billed as organ or disease panels. Effective October 1, 2003, all ESRD clinical laboratory tests must be billed individually. Effective January 1, 2011 With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base rate. If the ESRD facility needs to report a lab service that was not related to the treatment of ESRD, they must include the modifier AY to indicate the item or service is not for the treatment of ESRD. Modifiers CD, CE, and CF (also known as the 50/50 rule modifiers) are no longer valid for use on independent laboratory claims. Effective January 1, 2012, A/B MACs (B) shall allow organ disease panel codes (i.e., HCPCS codes 80047, 80048, 80051, 80053, 80061, 80069, and 80076) to be billed by independent laboratories for AMCC panel tests furnished to ESRD eligible beneficiaries. For more information regarding billing of AMCC tests for ESRD beneficiaries, see Section 40.6.1 of this manual.