Claims received with both a Code 1 and Code 2 procedure will reject the Code 2 procedure code when the Modifier indicator is 0 or 9, even when a modifier is appended. If the claim contains a valid modifier (e.g., 25, 58, 59, 76, 77, 78, 91, XE, XP, XS, or XU) on the Code 2 procedure and the Modifier indicator is 1, the service will receive separate reimbursement.
Outpatient facility claims reimbursed under Enhanced Ambulatory Patient Groups (EAPGs) billed on the UB-04 Claim Form must use modifiers 25 or 59 to bypass payment consolidation for separate visits or procedures. Modifiers XE, XP, XS, and XU will not bypass consolidation for separate procedures processed under EAPGs.
Note: Providers should check the CPT manual and CMS Medicare NCCI Policy information to ensure adding a modifier is appropriate for their specific situation, as the CMS Medicare NCCI Policy may outline when a modifier is not acceptable and why.
When separate claims are received for the same date of service, one claim containing Code 1 and the other claim containing Code 2 of a code pair; the first claim received will receive reimbursement. The second claim will only receive reimbursement in the below situations.
- Claim two contained a Code 1 of a code pair and the paid claim contained a Code 2 with an appropriate modifier appended and the NCCI file lists the Code 2 with a modifier indicator of 1.
- Claim two contains a Code 2 of a code pair and the paid claim contained a Code 1 with an appropriate modifier appended and the NCCI file lists the Code 2 with a modifier indicator of 1.
- Claim two contains a Code 2 of a code pair with an appropriate modifier and the paid claim contained a Code without a modifier appended and the NCCI file lists the Code 2 with a modifier indicator of 1.
