NYS DOH July 2015 APGs Subject to Modifier U6 Policy for Free‐Standing DTC and Amb Surg
Effective Date: July 1, 2011
Revised for July 1, 2015 Updates
Free‐Standing DTC and Amb Surg Ancillary Policy: To receive payment based on normal APG payment logic for the ancillary procedure codes that group to the APGs listed below, modifier U6 must be coded at the line level. Column [E] shows how the line will pay when modifier U6 is coded. If modifier U6 is NOT coded on the line, then procedures that group to non‐packaged ancillary APGs will pay zero and procedures that group to packaged ancillary APGs will receive a payment reduction at the line level as listed below in column [F]. Each packaging ancillary will decrease the weight of the visit/episode by the procedure's APG weight, which essentially unpackages the ancillary by removing the portion of the visit/episode weight associated with the packaged line. APGs NOT on this list will be reimbursed based on the normal APG payment logic whether or not modifier U6 is on the line. Please see the Modifier U6 policy for more information. Hospital Based Ancillary Policy: Hospitals are not subject to the U6 modifier policy. Columns [E] and [F] do not apply to hospital claims. [A]
[B]
[C]
[D]
[E]
[F]
Line Level Payment Action
APG
81
149
211
281
282
283
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
330
331
332
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
470
471
486
APG Description
APG Type
ECHOCARDIOGRAPHY
Diagnostic Significant P
SCREENING COLORECTAL SERVICES
Diagnostic Significant P
ELECTROENCEPHALOGRAM
Diagnostic Significant P
MAGNETIC RESONANCE ANGIOGRAPHY ‐ HEAD Radiologic Procedure
MAGNETIC RESONANCE ANGIOGRAPHY ‐ CHEST Radiologic Procedure
MAGNETIC RESONANCE ANGIOGRAPHY ‐ OTHER Radiologic Procedure
MAMMOGRAPHY
Radiologic Procedure
DIGESTIVE RADIOLOGY
Radiologic Procedure
DIAGNOSTIC ULTRASOUND EXCEPT Radiologic Procedure
VASCULAR DIAGNOSTIC ULTRASOUND OF Radiologic Procedure
PET SCANS
Radiologic Procedure
BONE DENSITOMETRY
Radiologic Procedure
MRI‐ ABDOMEN
Radiologic Procedure
MRI‐ JOINTS
Radiologic Procedure
MRI‐ BACK
Radiologic Procedure
MRI‐ CHEST
Radiologic Procedure
MRI‐ OTHER
Radiologic Procedure
MRI‐ BRAIN
Radiologic Procedure
CAT SCAN BACK
Radiologic Procedure
CAT SCAN ‐ BRAIN
Radiologic Procedure
CAT SCAN ‐ ABDOMEN
Radiologic Procedure
CAT SCAN ‐ OTHER
Radiologic Procedure
ANGIOGRAPHY, OTHER
Radiologic Procedure
ANGIOGRAPHY, CEREBRAL
Radiologic Procedure
LEVEL I DIAGNOSTIC NUCLEAR MEDICINE
Radiologic Procedure
LEVEL II DIAGNOSTIC NUCLEAR MEDICINE
Radiologic Procedure
LEVEL III DIAGNOSTIC NUCLEAR MEDICINE
Radiologic Procedure
LEVEL I PATHOLOGY
Ancillary
LEVEL II PATHOLOGY
Ancillary
PAP SMEARS
Ancillary
BLOOD AND TISSUE TYPING
Ancillary
LEVEL I IMMUNOLOGY TESTS
Ancillary
LEVEL II IMMUNOLOGY TESTS
Ancillary
LEVEL I MICROBIOLOGY TESTS
Ancillary
LEVEL II MICROBIOLOGY TESTS
Ancillary
LEVEL I ENDOCRINOLOGY TESTS
Ancillary
LEVEL II ENDOCRINOLOGY TESTS
Ancillary
LEVEL I CHEMISTRY TESTS
Ancillary
LEVEL II CHEMISTRY TESTS
Ancillary
BASIC CHEMISTRY TESTS
Ancillary
ORGAN OR DISEASE ORIENTED PANELS
Ancillary
TOXICOLOGY TESTS
Ancillary
THERAPEUTIC DRUG MONITORING
Ancillary
LEVEL I CLOTTING TESTS
Ancillary
LEVEL II CLOTTING TESTS
Ancillary
LEVEL I HEMATOLOGY TESTS
Ancillary
LEVEL II HEMATOLOGY TESTS
Ancillary
URINALYSIS
Ancillary
BLOOD AND URINE DIPSTICK TESTS
Ancillary
SIMPLE PULMONARY FUNCTION TESTS
Ancillary
OBSTETRICAL ULTRASOUND
Ancillary
PLAIN FILM
Ancillary
BASIC BLOOD TYPING
Ancillary
Modifier U6 coded on Modifier U6 NOT coded on line (provider not line (performed in responsible for service. house or provider will Lab/radiology provider will pay out to Packaged bill Medicaid directlly ) lab/radiology provider) APG?
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
No
No
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
pay as normal
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pay as normal
pay as normal
pay as normal
pay as normal
pay as normal
pay as normal
pay as normal
pay as normal
pay as normal
pay as normal
package as normal
pay as normal
pay as normal
pay as normal
package as normal
pay as normal
package as normal
pay as normal
package as normal
pay as normal
package as normal
pay as normal
package as normal
pay as normal
pay as normal
pay as normal
package as normal
pay as normal
package as normal
pay as normal
package as normal
package as normal
package as normal
pay as normal
package as normal
package as normal
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