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ACA Rate Increase for Specified Primary Care Services Implementation Update

April 11, 2014

The Patient Protection and Affordable Care Act (ACA) system enhancements are effective April 11, 2014. These enhancements include:

  • ACA rates being paid according to the geographic region of the provider
  • The application of ACA rates for Independent Non-Physician Medical Practitioners
  • The assignment of ACA rates to applicable Evaluation and Management and vaccine administration codes for regular claims processing

Note:

This will eliminate the need for weekly Accounts Receivable (A/R) payments. As a result, standard/existing claim specific information will be detailed on the Remittance Advice Details form instead of the A/R transaction information.

The ACA modifiers are now available for use.

ACA Modifiers
Modifier Description Modifier Description
XA ACA Level of Care 1 XG ACA Level of Care 7
XB ACA Level of Care 2 XH ACA Level of Care 8
XC ACA Level of Care 3 XI ACA Level of Care 9
XD ACA Level of Care 4 XJ ACA Level of Care 10
XE ACA Level of Care 5 XK ACA Level of Care 11
XF ACA Level of Care 6 XL ACA Level of Care 12

Note:

All existing billing procedures shall continue to apply. If billing with an existing modifier for the local code for any reason, providers should continue to use that modifier. After all existing modifiers have been entered, the new ACA modifier should be billed in the next available modifier field position on the claim form or electronic transaction.

If providers are currently not using an existing modifier, the ACA modifier should be billed in the first modifier field on the claim form or electronic transaction. Local codes currently have none, one or two existing modifiers. The current limit of four modifiers is not expected to be an issue when billing.

HCPCS Local Code to CPT-4 Crosswalk
Local Code Description ACA Modifier CPT-4 Code
X4544 Diagnostic evaluation for severely handicapped, age greater than 7 years XA 99241
XB 99242
XC 99243
XD 99244
XE 99245
X9544 Case conference, 30 minutes XA 99368
XB 99366
X9546 Case conference, one complete hour (maximum) XA 99368
XB 99366
Z0100 NICU and PICU – initial 24 hours admit XA 99292
XB 99222
XC 99223
XD 99291
XE 99477
XF 99475
XG 99471
XH 99468
Z0102 NICU and PICU – subsequent CAT 1 [vent, CPAP, drug sup, etc.] XA 99232
XB 99233
XC 99480
XD 99292
XE 99479
XF 99478
XG 99291
XH 99476
XI 99469
XJ 99472
Z0104 NICU and PICU – subsequent CAT 2 [sup oxy, meds/feeds, etc.] XA 99232
XB 99233
XC 99480
XD 99292
XE 99479
XF 99478
XG 99291
XH 99476
XI 99469
XJ 99472
Z0106 NICU and PICU – subsequent CAT 3 [freq/cardiac monitor, etc.] XA 99232
XB 99233
XC 99480
XD 99292
XE 99479
XF 99478
XG 99291
XH 99476
XI 99469
XJ 99472
Z0108 NICU and PICU – subsequent CAT 4 [routine day prior to DC] XA 99232
XB 99238
XC 99233
XD 99239
XE 99480
XF 99292
XG 99479
XH 99478
XI 99291
XJ 99476
XK 99469
XL 99472
Z0334 Lead Screen/Counsel & Blood Draw XA 99211
XB 99201
Z4302 EPSDT services/CCS/SCC medical case conference, other allied health care professional, 15 minutes XA 99368
XB 99366
Z4310 EPSDT services/CCS/SCC medical case conference, nurse specialist, 15 minutes XA 99368
XB 99366
Z4311 EPSDT services/CCS/SCC medical case conference, medical social worker, 15 minutes XA 99368
XB 99366
Z4312 EPSDT services/CCS/SCC medical case conference, registered dietician, 15 minutes XA 99368
XB 99366
Z5902 EPSDT services – initial audiology evaluation, age 2 – 5 years XA 99243
XB 99244
XC 99245
Z5904 EPSDT services – initial audiology evaluation, age 6 – 20 years XA 99243
XB 99244
Z5908 EPSDT services – subsequent audiology evaluation, age 2 – 5 years XA 99242
XB 99243
Z5950 EPSDT services – counseling by audiologist of patient and family regarding cochlear implantation, per hour XA 99355
XB 99354
Z5966 EPSDT services – patient and caregiver cochlear implant orientation, per hour XA 99355
XB 99354