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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Ambulatory Patient Groups (APG) Payment Modifiers – Effective 1/1/2012

Modifier Type Applicability and Payment Code (CPT or Modifier)
After-hours This modifier is applicable when services to adults or children are provided weekdays before 8:00 a.m., weekdays 6:00 p.m. or later, or all day on weekends. Services must begin before 8:00 a.m. or 6:00 p.m. or later.

In order to claim this modifier for all procedures except crisis services, the procedure must be provided during the extended hours of operation listed on the clinic’s operating certificate. If a clinic currently has extended hours, the modifier can be claimed during these times. Clinics without extended hours that wish to bill this modifier must have an approved change in their operating certificate before being able to bill the modifier. Only services provided after such approval are subject to the modifier.

The “after-hours” modifier will be recorded using Current Procedural Terminology (CPT) code 99051. It is reported in addition to the CPT code for each particular service or services provided after hours. The CPT code 99051 is weighted at .0759 of the clinic’s peer group base rate.

Medicaid will reimburse for only one after-hours CPT code per Medicaid recipient per day.

99051 (CPT code)
Language other than English This modifier is applicable when the service to the recipient and/or collateral is provided in a language other than English, including sign language. Translation may be provided by a staff person fluent in the language or by a paid translator.

It is expected that the individual providing language assistance services will have a sufficient level of fluency to ensure effective communication. Clinics should develop a process to assess or verify the language competency of those persons who will be providing language assistance services. Resources might include local organizations, universities or schools where the relevant languages are taught. In all instances, the confidentiality of information and respect for those served and for their culture must be assured.

Although the use of friends or family members as interpreters is not generally recommended, it is not prohibited. However, decisions to do so should be subject to careful clinical review and should be documented. It is critical to remember that the “language other than English” billing modifier cannot be utilized when translation is provided by a friend or family member.

The use of language assistance services and the method of providing the service should be documented in a progress note.

This modifier pays an additional 10% of the APG portion of payment.

U4 (Modifier)
Reduced Services  for School-based session For school-based group psychotherapy service, the duration of the service may be that of the school period provided the school period is of duration of at least 40 minutes.

When the service meets the time requirement the clinic will claim Medicaid using the U5 modifier.

This modifier will reduce the APG portion of payment by 30%.

U5 (Modifier)
Physician Add-on Clinics may claim the physician add-on when a psychiatrist, physician practicing in lieu of a psychiatrist with approval by OMH or psychiatric nurse practitioner spends at least 15 minutes participating in the provision of services being provided by another licensed practitioner or when the service is provided fully by a psychiatrist/ Nurse Practitioner in Psychiatry (NPP).

The add-on can also be claimed for each recipient when a psychiatrist/NPP runs a group session or participates in the group for at least 15 minutes.

This modifier will add 45% to the APG portion of payment for the individual service and will add 20% to the APG portion of payment for group services for each recipient participating in the group.

AF (psychiatrist) (Modifier)
AG (Physician) (Modifier)
SA (Nurse Practitioner) (Modifier)
Injectable Medication Administration This FB modifier applies to the Injection Only procedure (no time limit) when the medication is not purchased by the clinic. In this case, the clinic will add an FB Modifier to the J-code for the medication and submit the claim through the APG system. The FB modifier tells the Electronic Medicaid of New York (eMedNY) eMedNY system that the clinic did not pay for the drug but the clinic did provide an injection.

The clinic will receive $13.23 for the injection.

The language other than English modifier (U4) is not available.

If the clinic pays for the drug, the claim for the drug and the injection only procedure (no time limit) is submitted using the fee schedule. The clinic must include both the appropriate J-code and CPT code 96372 for the injection.

The clinic will receive payment for the drug cost and $13.23 for the injection.

There are no modifiers with the fee-schedule.

FB (Modifier)
Smoking Cessation Counseling (SCC) – Group Session Appropriate when providing a group SCC session (up to eight patients in a group) 

Using this modifier will result in reimbursement of $8.50 per participant

HQ (Modifier)

Comments or questions about the information on this page can be directed to the Bureau of Financial Planning.