Changes: HIPAA Code Conversion for Local Modifier ZS
| To: | Health Plan of San Joaquin (HPSJ) Providers |
| From: | Provider Services Department |
| Subject: | Changes: HIPAA Code Conversion for Local Modifier ZS |
| Products: | Medi-Cal, AIM |
| Effective Date: | August 1, 2015 |
An article that published in the April 2015 Medi-Cal Update announced that the effective date for the discontinuation of local modifier ZS would be July 1, 2015. Local modifier ZS designates both the professional (26) and technical (TC) components of a split-billable procedure on a claim or Prior Authorization Request (PA). However, in order to allow sufficient time for providers to make the necessary changes, Medi-Cal has extended the effective date for this policy to August 1, 2015.
Effective for dates of service on or after August 1, 2015, the Department of Health Care Services (DHCS) is discontinuing local modifier ZS. Modifier ZS designates both the professional (26) and technical (TC) components of a split-billable procedure on a claim or PA. When billing for both the professional and technical components, a modifier is neither required nor allowed. This change is to continue HIPAA compliance efforts and to align with the Centers for Medicare & Medicaid Services (CMS) guidelines.
Effective for dates of service on or after August 1, 2015, providers who previously submitted claims or PA’s for split-billable procedures using local modifier ZS are instructed to submit claims and PA’s without a modifier.
Claim Completion
Except for MRI, MRA or PET procedures, providers will be instructed to use one of the following methods when submitting a claim for both the professional and technical components of split-billable procedures. See the relevant sections of the Medi-Cal Provider Manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.
Physician Billing
- The physician bills for both the professional and technical components and then reimburses the facility for the technical component, according to their mutual agreements.
- The physician submits a CMS-1500 claim form with the procedure code on one claim
line without a modifier in the Procedures, Services or Supplies/Modifier field (Box
24D).
Facility Billing
- The facility bills for both the technical and professional components and then reimburses the physician for the professional component, according to their mutual agreements.
- The facility submits a UB-04 claim form with the procedure code on one claim line without a modifier in the HCPCS/Rate/HIPPS Code field (Box 44).
Prior Authorization Request (PA) Completion
- Except for MRI, MRA or PET procedures, providers will be instructed to use the following method when submitting a PA for both the professional and technical components of split-billable procedures. See the relevant sections of the Medi-Cal Provider Manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.
- A provider submits the PA with the procedure code on one service line without a modifier.
If you have any further questions, please contact our Provider Services Department at (209) 942-6340.
Additional Resource:
Medi-Cal Website (www.medi-cal.ca.gov) and go to Newsflash or Bulletins for further detail.