Status Indicators

Status Indicators

This information is from the Medicare Claims Processing Manual, Chapter 23 (PDF). For Medicare Physician Fee Schedule Database (MPFSDB) file layout information for years before 2018, choose the Historical MPFSDB Layouts (PDF) link from the Downloads section of the Physician Fee Schedule webpage.

Note: Because Medicare only updates Chapter 23 every year, it’s important to also review MLN Matters® articles and other information from CMS.

A = Active code. Medicare pays these codes separately under the physician fee schedule (PFS), if covered. Codes with this status include RVUs and payment amounts. The presence of an A indicator doesn’t mean that Medicare has made a national coverage determination about the service. A/B MACs (B) stay responsible for coverage decisions in the absence of a national Medicare policy.

B = The PFS always bundles payment for covered services into payment for other services not specified. No RVUs or payment amounts exist for these codes and Medicare never makes separate payment. When Medicare covers these services, we include payment for them in the payment for the services to which they’re incident. An example is a telephone call from a hospital nurse about the care of a patient.

C = A/B MACs (B) price the code. A/B MACs (B) set up RVUs and payment amounts for these services, generally on an individual case-by-case basis following review of documentation such as an operative report.

E = Excluded from physician fee schedule by regulation. CMS excludes these codes for items or services from the fee schedule payment by regulation. The PFSDB Status Indicators table doesn’t show any RVUs or payment amounts and makes no payment under the fee schedule for these codes. Payment for them, when covered, continues under reasonable charge procedures.

I = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. This code isn’t subject to a 90-day grace period.

J = Anesthesia services; no relative value units or payment amounts for anesthesia codes on the database, only used to help with the identification of anesthesia services.

L = Local codes. A/B MACs (B) will apply this status to all local codes in effect on January 1, 1998, or those later approved by central office for use. A/B MACs (B) will complete the RVUs and payment amounts for these codes.

M = Measurement codes. Used for reporting purposes only.

N = Non-covered service. Medicare carries these codes on the HCPCS tape as noncovered services.

P = Bundled and excluded codes. No RVUs exist for these services. Medicare doesn’t make separate payment for them under the fee schedule. If we cover the item or service as incident to a physician service and you provide it on the same day as a physician service, we bundle payment for it into the payment for the physician service to which it’s incident. An example is an elastic bandage a physician provided incident to a physician service. If Medicare covers the item or service as other than incident to a physician service, we exclude it from the fee schedule (for example, colostomy supplies) and pay it under the other payment provision of the Social Security Act.

Q = Therapy functional information code. Used for reporting purposes only. This indicator is no longer effective starting with the 2020 fee schedule as of January 1, 2020.

R = Restricted coverage. Special coverage instructions apply.

T = RVUs and payment amounts exist for these services. Medicare only pays these codes if no other services are payable under the physician fee schedule (PFS) billed on the same date by the same provider. If Medicare pays the same provider for any other services billed on the same date under the PFS, we bundle these services into the physician services.

X = Statutory exclusion. These codes stand for an item or service that isn’t in the legal definition of physician services for fee schedule payment purposes. The PFSDB Status Indicators table shows no RVUs or payment amounts for these codes and makes no payment under the PFS. Examples: Medicare excludes ambulance services and clinical diagnostic laboratory services.

Global Surgery

This field gives the postoperative timeframes that apply to payment for each surgical procedure or another indicator that describes how the global concept applies to the service.

000 = Medicare includes endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only in the fee schedule payment amount. Medicare doesn’t generally pay evaluation and management (E/M) services on the day of the procedure.

010 = Medicare includes minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period in the fee schedule amount. Medicare doesn’t generally pay E/M services on the day of the procedure and during this 10-day postoperative period.

090 = Medicare includes 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 doesn’t apply.

XXX = Global concept doesn’t apply.

YYY = A/B MAC decides whether global concept applies and establishes postoperative period at time of pricing.

ZZZ = Code related to another service. Medicare always includes it in the global period of the other service.

Note: Physician work is associated with intra-service time and sometimes the post service time.

Preoperative Percentage (Modifier 56)

This field has the percentage, shown in decimal format, for the preoperative part of the global package. For example, 10% shows as 010000. The total of the preoperative percentage, intraoperative percentage, and the postoperative percentage fields will usually equal 1. Any variance is slight and results from rounding.

Intraoperative Percentage (Modifier 54)

This field has the percentage, shown in decimal format, for the intraoperative part of the global package including postoperative work in the hospital. For example, 63% shows as 063000. The total of the preoperative percentage, intraoperative percentage, and the postoperative percentage fields will usually equal 1. Any variance is slight and results from rounding.

Postoperative Percentage (Modifier 55)

This field has the percentage, shown in decimal format, for the postoperative part of the global package that’s provided in the office after discharge from the hospital. For example, 17% shows as 017000. The total of the preoperative percentage, intraoperative percentage, and the postoperative percentage fields will usually equal 1. Any variance is slight and results from rounding.

Professional Component (PC) or Technical Component (TC) Indicator

0 = Physician service codes. This indicator describes physician service codes. Examples include visits, consultations, and surgical procedures. The concept of PC or TC doesn’t apply since Medicare doesn’t split physician services into professional and technical components. You can’t use Modifiers 26 and TC with these codes. The total Relative Value Units (RVUs) include values for physician work, practice expense, and malpractice expense. Medicare includes physician service codes with no work RVUs.

1 = Diagnostic tests or radiology services. This indicator describes diagnostic tests codes (for example, pulmonary function tests or therapeutic radiology procedures like radiation therapy). These codes generally have both a professional and technical component. You can use Modifiers 26 and TC with these codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense. 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 part of chosen diagnostic tests for which there’s 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. You can’t use modifiers 26 and TC 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 describes stand-alone codes that describe the technical component, like staff and equipment costs, of chosen diagnostic tests for which there’s 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 describes codes that Medicare covers only as diagnostic tests and don’t have a related professional code. You can’t use Modifiers 26 and TC 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 describes stand-alone codes that have associated codes naming:

• The professional component of the test only
• The technical component of the test only

You can’t use modifiers 26 and TC 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 equal the sum of the total RVUs for the professional and technical components only codes together.

5 = Incident to codes. This indicator describes codes for services covered incident to a physician’s service when auxiliary personnel the physician employs and who work under their direct supervision provides them. MACs may not make payment for these services when auxiliary personnel provide them to hospital inpatients or patients in a hospital outpatient department. You can’t use modifiers 26 and TC with these codes.

6 = Laboratory physician interpretation codes. This indicator describes clinical laboratory codes for interpretations by laboratory physicians. Medicare pays separately for these services. Medicare pays the laboratory physician for doing the tests under the lab fee schedule. You can’t use modifier TC 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. Medicare may not make payment if an independently practicing physical therapist or occupational therapist provided the service to a hospital outpatient or inpatient.

8 = Physician interpretation codes. This indicator describes the professional component of clinical laboratory codes. Medicare may make separate payment only if the physician interprets an abnormal smear for a hospital inpatient. This applies only to code 85060. Medicare doesn’t recognize TC billing because we make payment for the underlying clinical laboratory test to the hospital, generally through the Prospective Payment System (PPS) rate. Medicare doesn’t make payment for code 85060 provided to hospital outpatients or non-hospital patients. Medicare pays the physician interpretation through the clinical laboratory fee schedule (CLFS) payment for the clinical laboratory test.

9 = Concept of a professional or technical component doesn’t apply.

Multiple Procedure (CPT Modifier 51)

This indicator shows which payment adjustment rule for multiple procedures applies to the service.

0 = No payment adjustment rules for multiple procedures apply. If you report the procedure on the same day as another procedure, payment is based on the lower of:

• The actual charge
• 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 applied 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, Medicare ranks the procedures by the fee schedule amount and applies the correct reduction to this code (100%, 50%, 25%, 25%, 25%, and by report). MACs base payment on the lower of:

• The actual charge
• The fee schedule amount reduced by the right percentage

2 = Standard payment adjustment rules for multiple procedures apply. If you report the procedure on the same day as another procedure with an indicator of 1, 2, or 3, MACs rank the procedures by fee schedule amount and apply the reduction to this code (100%, 50%, 50%, 50%, 50%, and by report). MACs base payment on the lower of:

• The actual charge
• The fee schedule amount reduced by the correct percentage

3 = Special rules for multiple endoscopic procedures apply if you bill the procedure with another endoscopy in the same family (that is, another endoscopy that has the same base procedure). You show the base procedure for each code with this indicator in the endoscopic base code field. The multiple endoscopy rules apply to a family before ranking the family with other procedures done on the same day (for example, if you report multiple endoscopies in the same family on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If you report an endoscopic procedure with only its base procedure, Medicare doesn’t pay the base procedure separately. We include payment for the base procedure in the payment for the other endoscopy.

4 = Diagnostic imaging services subject to the MPPR. TC of diagnostic imaging services subject to a 50% reduction of the second and subsequent imaging services furnished by the same physician (or by multiple physicians in the same group practice, for example, same group National Provider Identifier [NPI]) to the same patient on the same day, effective for services July 1, 2010, and after. PC of diagnostic imaging services are subject to a 5% payment reduction of the second and subsequent imaging services effective January 1, 2017.

Medicare doesn’t include multiple procedure indicator 5 in this file, since the indicator stands for the therapy multiple procedure payment reduction which never applies to professional service revenue codes. Medicare doesn’t include multiple procedure indicators 6 and 7 in this file, since in these cases the reduction only applies to technical component services. On CAH claims, Medicare pays technical components on a cost basis, and they aren’t subject to the reductions.

Tip: Refer to MLN Matters® Article MM9647 about the 5% reduction to the PC for certain diagnostic imaging procedures.

9 = Concept doesn’t apply.

The payment Indicator file doesn’t include codes with RVUs equal to zero. These codes may have multiple procedure indicators not shown.

Bilateral Surgery Indicator (CPT Modifier 50)

This field gives an indicator for services subject to a payment adjustment.

0 = 150% payment adjustment for bilateral procedures doesn’t apply. The bilateral adjustment isn’t right for codes in this category because of:

• Physiology or anatomy
• The code descriptor specifically states that it’s a unilateral procedure and there’s an existing code for the bilateral procedure

1 = 150% payment adjustment for bilateral procedures applies. If you bill a code with the bilateral modifier, Medicare bases payment for these codes, when reported as bilateral procedures, on the lower of:

• The total actual charge for both sides
• 150% of the fee schedule amount for a single code

If you report a code as a bilateral procedure with other procedure codes on the same day, Medicare applies the bilateral adjustment before applying any applicable multiple procedure rules.

2 = 150% payment adjustment for bilateral procedure doesn’t apply. Medicare bases RVUs on the procedure providers do as a bilateral procedure. Medicare bases RVUs on a bilateral procedure because:

• The code descriptor specifically states that the procedure is bilateral
• The code descriptor states that the procedure may be performed either unilaterally or bilaterally
• You usually do the procedure as a bilateral procedure

3 = The usual payment adjustment for bilateral procedures doesn’t apply. Services in this category are generally radiology procedures or other diagnostic tests which aren’t subject to the special payment rules for other bilateral procedures. If you bill the procedure with modifier 50, Medicare bases payment on the lesser of:

• The actual charge for each side
• 100% of the fee schedule amount for each side

If you report a procedure as a bilateral procedure and with other procedure codes on the same day, the fee schedule amount for a bilateral procedure is determined before applying any applicable multiple procedure rules.

Services in this category are generally radiology procedures or other diagnostic tests which aren’t subject to the special payment rules for other bilateral procedures.

9 = Concept doesn’t apply.

Assistant at Surgery (Modifiers AS, 80, 81, and 82)

This field gives an indicator for services where Medicare never pays an assistant at surgery.

0 = Payment restriction for assistants at surgery applies to this procedure unless you send in supporting documentation to prove medical necessity.

1 = Statutory payment restriction for assistants at surgery applies to this procedure. Medicare may not pay assistants at surgery.

2 = Payment restriction for assistants at surgery don’t apply to this procedure. Medicare may pay assistants at surgery.

9 = Concept doesn’t apply.

Co-Surgeons (Modifier 62)

This field gives an indicator for services for which Medicare may pay 2 surgeons, each in a different specialty.

0 = Co-surgeons not allowed for this procedure.

1 = Co-surgeons could be paid. Medicare requires supporting documentation to prove medical necessity of 2 surgeons for the procedure.

2 = Co-surgeons allowed. Medicare doesn’t require documentation if you meet the 2 specialty requirements.

9 = Concept doesn’t apply.

Team Surgeons (Modifier 66)

This field gives an indicator for services for which Medicare may pay team surgeons.

0 = Team surgeons not allowed for this procedure.

1 = Team surgeons could be paid. Medicare requires supporting documentation to prove medical necessity of a team. Paid by report.

2 = Team surgeons allowed. Pay by report.

9 = Concept doesn’t apply.

Endoscopic Base Codes

This field shows an endoscopic base code for each code with a multiple surgery indicator of 3.

Diagnostic Imaging Family Indicator

88 = Subject to the reduction for diagnostic imaging (effective for services January 1, 2011, and after).

99 = Concept doesn’t apply.

Physician Supervision of Diagnostic Procedures

Medicare uses this field in post payment review.

01 = Procedure must be furnished under the general supervision of a physician.

02 = Procedure must be furnished under the direct supervision of a physician.

03 = Procedure must be furnished under the personal supervision of a physician. A registered radiologist assistant (RRA) who’s certified and registered by The American Registry of Radiologic Technologists (ARRT) or a radiology practitioner assistant (RPA) certified by the Certification Board for Radiology Practitioner Assistants (CBRPA), can do diagnostic imaging procedures under direct supervision. State law must authorize the RRA or RPA to provide the procedure.

04 = Physician supervision policy doesn’t apply when a qualified, independent psychologist or a clinical psychologist furnishes a procedure. Otherwise, a physician must generally supervise the procedure.

05 = Not subject to supervision when a qualified audiologist, physician, or nonphysician practitioner furnishes the procedure personally. A physician must directly supervise those parts of the test that a qualified technician may provide when proper.

06 = A physician or physical therapist (PT) certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiological clinical specialist and allowed to provide the procedure under state law, must personally do the procedure. A PT with ABPTS certification may also do the procedure without physician supervision.

21 = Procedure may be furnished by a technician with certification under general supervision of a physician. Otherwise, a physician must directly supervise the procedure. A PT with ABPTS certification may also do the procedure without physician supervision.

22 = May be furnished by a technician with on-line real-time contact with a physician.

66 = May be personally furnished by a physician or by a PT with ABPTS certification and certification in this specific procedure.

6A = Supervision standards for level 66 apply. Also, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.

77 = Procedure must be furnished 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. Also, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.

09 = Concept doesn’t apply.

Diagnostic Imaging Family Indicator

For services effective January 1, 2011, and after, family indicators 01 - 11 won’t populate.

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 doesn’t apply