Adjustments to the Single Payment Amounts to Reflect Changes

100.5 - Adjustments to the Single Payment Amounts to Reflect Changes in HCPCS Codes (Rev. 1535, Issued: 06-13-08, Effective: 07-01-08, Implementation: 07-07-08) If new HCPCS codes are established following the start of a competitive bidding contract period that describe new technology items that did not previously fall under HCPCS codes for competitive bidding items, they will not be added to the competitive bidding HCPCS, CBA pricing and public use files. If a HCPCS code descriptor for a competitive bidding item is revised to clarify the item described by that code after the competitive bidding contract period begins, a corresponding code descriptor change will be made in the competitive bidding HCPCS, CBA pricing and public use files. Should a HCPCS code be deleted from the HCPCS after the competitive bidding contract period begins, the deleted code will be considered invalid for claims submission under the competitive bidding program and will be removed from the competitive bidding HCPCS, CBA pricing and public use files. Although the code is discontinued, as explained below, the items that previously fell under the code may continue to be subject to the competitive bidding program. If a HCPCS code for a competitive bidding item is revised after the contract period for a competitive bidding program begins, CMS will adjust the single payment amount(s) for the item(s) on the CBA pricing file for that Round using one of the following methods: a. If a single HCPCS code for an item is divided into two or more HCPCS codes for the components of that item, the sum of the single payment amounts for the new HCPCS codes will equal the single payment amount for the original item. In accordance with instructions provided in future recurring update notifications, the payment amounts for the HCPCS codes for the components will be established based on the corresponding fee schedule amounts for these codes that are established in accordance with section 60.3 of chapter 23 of the Claims Processing Manual. These amounts for the components of the item will then be adjusted by the same percentage to the level where the sum of the payment amounts for the HCPCS codes for the components equals the single payment amount for the item. b. If a single HCPCS code is divided into two or more separate HCPCS codes for different but similar items, the single payment amount for each of the new separate HCPCS codes is equal to the single payment amount applied to the original, single HCPCS code. c. If the HCPCS codes for components of an item are merged into a single HCPCS code for the item, the single payment amount for the new HCPCS code is equal to the total of the separate single payment amounts for the components. d. If multiple HCPCS codes for different but similar items are merged into a single HCPCS code, the items to which the new HCPCS codes apply may be furnished by any supplier that has a valid Medicare billing number. Payment for the new code will be based on the fee schedule methodology, even if single payment amounts were established for the discontinued multiple HCPCS codes. The old codes will be considered invalid and no longer included in the competitive bidding program for the remainder of the contract term. Contract suppliers must furnish the item(s) described by the new HCPCS code(s) in scenarios (a) through (c) above and submit claims using the new codes. Notification of a competitive bidding HCPCS code change will occur through program instruction. Addendum - MPFSDB File Record Layout and Field Descriptions (Rev. 12823, Issued:09-05- 24, Effective: 10-08-24, Implementation Date:10-08-24) The CMS MPFSDB includes the total fee schedule amount, related component parts, and payment policy indicators. The record layout is provided below. Beginning with the 2019 MPFSDB, and thereafter, the MPFSDB File Record Layout will no longer be revised annually in this section for the sole purpose of changing the calendar year, but will only be revised when there is a change to a field. Previous MPFSDB file layouts (for 2018 and prior) can be found on the CMS web site on the Physician Fee Schedule web page at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/index.html. MPFSDB File Layout HEADER RECORD FIELD # DATA ELEMENT NAME LOCATION PIC 1 Header ID 1-4 x(4) Value “Head" 2 Header Number 5 x(1) 3 Data Set Name 6-50 x(45) 4 Record Length 51-53 x(3) 5 Filler 54-54 x(1) 6 Block size 55-58 x(4) 7 Filler 59-59 x(1) 8 Number of Records Number does not include this header record. 60-69 9(10) 9 Date Created 70-77 x(8) YYYYMMDD 10 Blanks 78-345 x(268) DATA RECORD FIELD # & ITEM LENGTH & PIC 1 File Year This field displays the effective year of the file. 4 Pic x(4) 2 A/B MAC (B) Number This field represents the 5-digit number assigned to the A/B MAC (B). 5 Pic x(5) 3 Locality This 2-digit code identifies the pricing locality used. 2 Pic x(2) 4 HCPCS Code This field represents the procedure code. Each A/B MAC (B) Current Procedural Terminology (CPT) code (other than codes for Multianalyte Assays with Algorithmic Analyses (MAAA) and Proprietary Laboratory Analyses (PLA)) and alpha-numeric HCPCS codes other than B, C, E, K, L and U codes will be included. The standard sort for this field is blanks, alpha, and numeric in ascending order. Note: MAAA and PLA are alpha-numeric CPT codes. 5 Pic x(5) 5 Modifier 2 Pic x(2) FIELD # & ITEM LENGTH & PIC For diagnostic tests, a blank in this field denotes the global service and the following modifiers identify the components: 26 = Professional component 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 through stoma code 44388, 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 threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. 6 Descriptor This field will include a brief description of each procedure code. 50 Pic x(50) 7 Code Status This 1 position field provides the status of each code under the full fee schedule. Each status code is explained in §30.2.2. 1 Pic x(1) 8 Conversion Factor This field displays the multiplier which transforms relative values into payment amounts. The file will contain the conversion factor for the File Year which will reflect all adjustments. 8 Pic 9(4)v9999 9 Update Factor This update factor has been included in the conversion factor in Field 8. 6 Pic 9(2)v9999 10 Work Relative Value Unit This field displays the unit value for the physician work RVU. 9 Pic 9(7)v99 FIELD # & ITEM LENGTH & PIC 11 Filler 9 Pic 9(7)v99 12 Malpractice Relative Value Unit This field displays the unit value for the malpractice expense RVU. 9 Pic 9(7)v99 13 Work Geographic Practice Cost Indices (GPCIs) This field displays a work geographic adjustment factor used in computing the fee schedule amount. 5 Pic 99v999 14 Practice Expense GPCI This field displays a practice expense geographic adjustment factor used in computing the fee schedule amount. 5 Pic 99v999 15 Malpractice GPCI This field displays a malpractice expense geographic adjustment factor used in computing the fee schedule amount. 5 Pic 99v999 16 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. XXX = Global concept does not apply. YYY = A/B MAC (B) determines whether global concept applies and establishes postoperative period, if appropriate, at time of pricing. 3 Pic x(3) FIELD # & ITEM LENGTH & PIC 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.) 17 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 fields 17, 18, and 19 will usually equal one. Any variance is slight and results from rounding. 6 Pic 9v9(5) 18 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 fields 17, 18, and 19 will usually equal one. Any variance is slight and results from rounding. 6 Pic 9v9(5) 19 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 total of fields 17, 18, and 19 will usually equal one. Any variance is slight and results from rounding. 6 Pic 9v9(5) 20 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. 1 Pic x(1) FIELD # & ITEM LENGTH & PIC 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: 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, 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 A/B MACs (B) 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. FIELD # & ITEM LENGTH & PIC 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 = Private practice therapist’s service: Payment may not be made if the service is provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or speech- language pathologist in private practice. 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 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. 21 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 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 procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee 1 Pic (x)1 FIELD # & ITEM LENGTH & PIC schedule amount and apply the appropriate reduction to this code (100 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 field 31G. 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% 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. 22 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. If procedure is reported with modifier -50 or with 1 Pic (x)1 FIELD # & ITEM LENGTH & PIC modifiers RT and LT, base payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). 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 = 150 percent payment adjustment for bilateral procedures applies. If code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), 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. If procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the units field), base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). 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. If procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and FIELD # & ITEM LENGTH & PIC LT modifiers or with a 2 in the units field), base payment for each side or organ or site of a paired organ on the lower of: (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any applicable multiple procedure rules. 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. 9 = Concept does not apply. 23 Assistant at Surgery This field provides an indicator for services where an assistant at surgery is never paid for per IOM. 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. 1 Pic (x)1 24 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 25 Team Surgeons (Modifier 66) This field provides an indicator for services for which team surgeons may be paid. 0 = Team surgeons not permitted for this procedure. 1 = Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report. 1 Pic (x)1 FIELD # & ITEM LENGTH & PIC 2 = Team surgeons permitted; pay by report. 9 = Concept does not apply. 26 Filler 1 Pic (x)1 27 Site of Service Differential For 1999 and beyond, the site of service differential no longer applies. The following definitions will apply for all years after 1998: 0 = Facility pricing does not apply. 1 = Facility pricing applies. 9 = Concept does not apply. 1 Pic (x)1 28 Non-Facility Fee Schedule Amount This field shows the fee schedule amount for the non-facility setting. This amount equals Field 34. Note: Field 33 D indicates if an additional adjustment should be applied to this formula. Non-Facility Pricing Amount for the File Year [(Work RVU * Work GPCI) + ( Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor 9 Pic 9(7)v99 29 Facility Fee Schedule Amount This field shows the fee schedule amount for the facility setting. This amount equals Field 35. Note: Field 33D indicates if an additional adjustment should be applied to this formula. Facility Pricing Amount for the File Year [(Work RVU * Work GPCI) + ( Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor Place of service codes to be used to identify facilities. 02 – Telehealth-Provided Other than in Patient’s Home. 19 – Off Campus-Outpatient Hospital 21 - Inpatient Hospital 22 – On Campus-Outpatient Hospital 9 Pic 9(7)v99 FIELD # & ITEM LENGTH & PIC 23 - Emergency Room - Hospital 24 - Ambulatory Surgical Center – In a Medicare approved ASC, for an approved procedure on the ASC list, Medicare pays the lower facility fee to physicians. Beginning with dates of service January 1, 2008, in a Medicare approved ASC, for procedures NOT on the ASC list of approved procedures, contractors will also pay the lower facility fee to physicians. 26 - Military Treatment Facility 31 - Skilled Nursing Facility 34 - Hospice 41 - Ambulance - Land 42 - Ambulance Air or Water 51 - Inpatient Psychiatric Facility 52 - Psychiatric Facility Partial Hospitalization 53 - Community Mental Health Center 56 - Psychiatric Residential Treatment Facility 61 - Comprehensive Inpatient Rehabilitation Facility 29A Anti-markup Test Indicator This field providers an indicator for Anti-markup Test HCPCS codes: ‘1’ = Anti-markup Test HCPCS. ‘9’ = Concept does not apply. 1 Pic x 30 Record Effective Date This field identifies the effective date for the MPFSDB record for each HCPCS. The field is in YYYYMMDD format. NOTE: This is not the date the HCPCS code was created. It is the date the code was updated or added to the MPFSDB file for the current file year. This field is set to January 1 for all codes during the annual update process. 8 Pic x(8) 31 Filler 28 Pic x(28) 31EE Reduced therapy fee schedule amount 9Pic(7)v99 31DD Filler 1Pic x(2) FIELD # & ITEM LENGTH & PIC 31CC Imaging Cap Indicator A value of “1” means subject to OPPS payment cap determination. A value of “9” means not subject to OPPS payment cap determination. 1Pic x(1) 31BB Non-Facility Imaging Payment Amount 9Pic(7)v99 31AA Facility Imaging Payment Amount 9Pic(7)v99 31A Physician Supervision of Diagnostic Procedures This field is for use in post payment review. 01 = Procedure must be performed under the general supervision of a physician. 02 = Procedure must be performed under the direct supervision of a physician. 03 = Procedure must be performed under the personal supervision of a physician. (Diagnostic imaging procedures performed by a Registered Radiologist Assistant (RRA) who is certified and registered by The American Registry of Radiologic Technologists (ARRT) or a Radiology Practitioner Assistant (RPA) who is certified by the Certification Board for Radiology Practitioner Assistants (CBRPA), and is authorized to furnish the procedure under state law, may be performed under direct supervision.) 04 = Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist; otherwise must be performed under the general supervision of a physician. 05 = Not subject to supervision when furnished personally by a qualified audiologist, physician or non physician practitioner. Direct supervision by a physician is required for those parts of the test that may be furnished by a qualified technician when appropriate to the circumstances of the test. 06 = Procedure must be personally performed by a physician or a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiological clinical specialist and is permitted to provide 2 Pic x(2) FIELD # & ITEM LENGTH & PIC the procedure under State law. Procedure may also be performed by a PT with ABPTS certification without physician supervision. 21 = Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician. Procedure may also be performed by a PT with ABPTS certification without physician supervision. 22 = May be performed by a technician with on-line real-time contact with physician. 66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure. 6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill. 77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC & PC), or by a technician with certification under general supervision of a physician (TC only; PC always physician). 7A = Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill. 09 = Concept does not apply. 31B This field has been deleted to allow for the expansion of field 31A. 31C Facility Setting Practice Expense Relative Value Units 9 Pic(7)v99 31D Non-Facility Setting Practice Expense Relative Value Units 9 Pic(7)v99 31E Filler 9 Pic(7)v99 31F Filler Reserved for future use. 1 Pic x(1) 31G Endoscopic Base Codes This field identifies an endoscopic base code for each code with a multiple surgery indicator of 3. 5 Pic x(5) FIELD # & ITEM LENGTH & PIC 32A 1996 Transition/Fee Schedule Amount This field is no longer applicable since transitioning ended in 1996. This field will contain a zero. 9 Pic 9(7)v99 32B 1996 Transition/Fee Schedule This field is no longer applicable since transitioning ended in 1996. This field will contain spaces. 1 Pic x(1) 32C 1996 Transition/Fee Schedule Amount When Site or Service Differential Applies This field is no longer applicable since transitioning ended in 1996. This field will contain a zero. 9 Pic 9(7)v99 33A Units Payment Rule Indicator Reserved for future use. 9 = Concept does not apply. 1 Pic x(1) 33B Mapping Indicator This field is no longer applicable since transitioning ended in 1996. This field will contain spaces. 1 Pic x(1) 33C Anti-markup Locality—Informational Use—Locality used for reporting utilization of anti-markup services. NOT FOR A/B MAC (B) USE: These Medicare Advantage encounter pricing localities are for Shared System Maintainer purposes only. The locality values were developed to facilitate centralized processing of encounter data by the Medicare Advantage organizations. 2 Pic x(2) 33D Calculation Flag This field is informational only; the SSMs do not need to add this field. The intent is to assist A/B MACs (B) to understand how the fee schedule amount in fields 28 and 29 are calculated. The MMA mandates an additional adjustment to selected HCPCS codes. A value of “1” indicates an additional fee schedule adjustment of 1.32 in 2004 and 1.03 in 2005. A value of “0” indicates no additional adjustment needed. A value of “2” indicates an additional fee schedule adjustment of 1.05 effective 7/1/2008. 1 Pic x(1) FIELD # & ITEM LENGTH & PIC 33 E Diagnostic Imaging Family Indicator For services effective January 1, 2011, and after, family indicators 01 - 11 will not be populated. 01 = Family 1 Ultrasound (Chest/Abdomen/Pelvis – Non Obstetrical 02 = Family 2 CT and CTA (Chest/Thorax/Abd/Pelvis) 03 = Family 3 CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck) 04 = Family 4 MRI and MRA (Chest/Abd/Pelvis) 05 = Family 5 MRI and MRA (Head/Brain/Neck) 06 = Family 6 MRI and MRA (spine) 07 = Family 7 CT (spine) 08 = Family 8 MRI and MRA (lower extremities) 09 = Family 9 CT and CTA (lower extremities) 10 = Family 10 Mr and MRI (upper extremities and joints) 11 = Family 11 CT and CTA (upper extremities) 88 = Subject to the reduction of the TC diagnostic imaging (effective for services January 1, 2011, and after). Subject to the reduction of the PC diagnostic imaging (effective for services January 1, 2012 and after). 99 = Concept Does Not Apply 2Pic x(2) 33F Performance Payment Indicator (For future use) 1 Pic x (1) 33G National Level Future Expansion 3 Pic x (3) 34 Non-Facility Fee Schedule Amount This field replicates field 28. 9 Pic 9(7)v99 35 Facility Fee Schedule Amount This field replicates field 29. 9 Pic 9(7)v99 36 Filler 1 Pic x(1) 37 7 Pic x(7) FIELD # & ITEM LENGTH & PIC Future Local Level Expansion** The Updated 1992 Transition Amount was previously stored in this field. A/B MACs (B) can continue to maintain the updated transition amount in this field. 38A Future Local Level Expansion** The adjusted historical payment basis (AHPB) was previously stored in this field. A/B MACs (B) can continue to maintain the AHPB in this field. 7 Pic x(7) 38 B Filler This field was originally established for 15 spaces. Since AHPB data will only use 7 of the 15 spaces, A/B MACs (B) have 8 remaining spaces for their purposes. ** These fields will be appended by each A/B MAC (B) at the local level. 8 Pix x(8)