Procedures Subject to the Ancillary Policy

NYS DOH APGs Subject to Modifier U6 Policy for Free–Standing DTC and Amb Surg

Effective Date: July 1, 2011

Revised for January 1, 2022 Updates

Free–Standing DTC and Amb Surg Ancillary Policy: To receive payment based on normal APG payment logic for the ancillary procedure codes that group to the APGs listed below, modifier U6 must be coded at the line level. Column [E] shows how the line will pay when modifier U6 is coded. If modifier U6 is NOT coded on the line, then procedures that group to non–packaged ancillary APGs will pay zero and procedures that group to packaged ancillary APGs will receive a payment reduction at the line level as listed below in column [F]. Each packaging ancillary will decrease the weight of the visit/episode by the procedure's APG weight, which essentially unpackages the ancillary by removing the portion of the visit/episode weight associated with the packaged line. APGs NOT on this list will be reimbursed based on the normal APG payment logic whether or not modifier U6 is on the line. Please see the Modifier U6 policy for more information.
Hospital Based Ancillary Policy: Hospitals are not subject to the U6 modifier policy. Columns [E] and [F] do not apply to hospital claims.
[A] [B] [C] [D] [E] [F] [G] [H]
  Line Level Payment Action
APG APG Description APG Type Packaged APG? Modifier U6 coded on
line (performed in
house or provider will
pay out to
lab/radiology provider)		 Modifier U6 NOT coded on
line (provider not
responsible for service.
Lab/radiology provider will
bill Medicaid directly )		 Date
Added
to List		 Date
Removed
from List
81 ECHOCARDIOGRAPHY Radiologic Procedure No pay as normal zero payment   1/1/2020
149 SCREENING COLORECTAL SERVICES Diagnostic or Therapeutic Proc No pay as normal zero payment    
211 ELECTROENCEPHALOGRAM Diagnostic or Therapeutic Proc No pay as normal zero payment   1/1/2020
277 LEVEL I VASCULAR RADIOLOGICAL PROCEDURES Radiologic Procedure No pay as normal zero payment 1/1/2020  
281 MAGNETIC RESONANCE ANGIOGRAPHY – HEAD AND/OR NECK Radiologic Procedure No pay as normal zero payment    
282 MAGNETIC RESONANCE ANGIOGRAPHY Radiologic Procedure No pay as normal zero payment    
283 MAGNETIC RESONANCE ANGIOGRAPHY – OTHER SITES Radiologic Procedure No pay as normal zero payment    
286 MAMMOGRAPHY & OTHER RELATED PROCEDURES Radiologic Procedure No pay as normal zero payment    
287 DIGESTIVE RADIOLOGY Radiologic Procedure No pay as normal zero payment    
288 LEVEL I DIAGNOSTIC ULTRASOUND Radiologic Procedure Yes package as normal payment reduction    
289 LEVEL II DIAGNOSTIC ULTRASOUND Radiologic Procedure No pay as normal zero payment    
290 PET SCANS Radiologic Procedure No pay as normal zero payment    
291 BONE DENSITY AND RELATED PROCEDURES Radiologic Procedure Yes package as normal payment reduction    
292 MRI– ABDOMEN Radiologic Procedure No pay as normal zero payment    
293 MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST Radiologic Procedure No pay as normal zero payment    
294 MRI– BACK Radiologic Procedure No pay as normal zero payment    
295 MAGNETIC RESONANCE IMAGING WITH CONTRAST Radiologic Procedure No pay as normal zero payment    
296 MRI– OTHER Radiologic Procedure No pay as normal zero payment    
297 MAGNETOCEPHALOGRAPHY Radiologic Procedure No pay as normal zero payment    
298 CAT SCAN BACK Radiologic Procedure No pay as normal zero payment    
299 LEVEL I COMPUTED TOMOGRAPHY Radiologic Procedure No pay as normal zero payment    
300 LEVEL II COMPUTED TOMOGRAPHY Radiologic Procedure No pay as normal zero payment    
301 COMPUTED TOMOGRAPHY– OTHER Radiologic Procedure No pay as normal zero payment    
302 COMPUTED TOMOGRAPHIC ANGIOGRAPHY Radiologic Procedure No pay as normal zero payment    
303 ANGIOGRAPHY, CEREBRAL Radiologic Procedure No pay as normal zero payment    
308 LEVEL III PATHOLOGY TESTS Ancillary Yes package as normal payment reduction 1/1/2020  
330 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE Radiologic Procedure No pay as normal zero payment    
331 LEVEL I DIAGNOSTIC NUCLEAR MEDICINE Radiologic Procedure No pay as normal zero payment    
332 LEVEL II DIAGNOSTIC NUCLEAR MEDICINE Radiologic Procedure No pay as normal zero payment    
384 LEVEL III CHEMISTRY TESTS Ancillary Yes package as normal payment reduction 1/1/2020  
388 LEVEL III MICROBIOLOGY TESTS Ancillary No pay as normal zero payment 1/1/2020  
389 LEVEL II CONVENTIONAL RADIOLOGY Ancillary No pay as normal zero payment 1/1/2020  
390 LEVEL I PATHOLOGY TESTS Ancillary Yes package as normal payment reduction    
391 LEVEL II PATHOLOGY TESTS Ancillary No pay as normal zero payment    
392 PAP SMEARS Ancillary No pay as normal zero payment    
393 LEVEL II BLOOD AND TISSUE TYPING TESTS Ancillary No pay as normal zero payment    
394 LEVEL I IMMUNOLOGY TESTS Ancillary Yes package as normal payment reduction    
395 LEVEL II IMMUNOLOGY TESTS Ancillary No pay as normal zero payment    
396 LEVEL I MICROBIOLOGY TESTS Ancillary Yes package as normal payment reduction    
397 LEVEL II MICROBIOLOGY TESTS Ancillary No pay as normal zero payment    
398 LEVEL I ENDOCRINOLOGY TESTS Ancillary Yes package as normal payment reduction    
399 LEVEL II ENDOCRINOLOGY TESTS Ancillary No pay as normal zero payment    
400 LEVEL I CHEMISTRY TESTS Ancillary Yes package as normal payment reduction    
401 LEVEL II CHEMISTRY TESTS Ancillary No pay as normal zero payment    
402 BASIC CHEMISTRY TESTS Ancillary Yes package as normal payment reduction    
403 ORGAN OR DISEASE ORIENTED PANELS Ancillary No pay as normal zero payment    
404 TOXICOLOGY TESTS Ancillary Yes package as normal payment reduction    
405 THERAPEUTIC DRUG MONITORING Ancillary Yes package as normal payment reduction    
406 LEVEL I CLOTTING TESTS Ancillary Yes package as normal payment reduction    
407 LEVEL II CLOTTING TESTS Ancillary No pay as normal zero payment    
408 LEVEL I HEMATOLOGY TESTS Ancillary Yes package as normal payment reduction    
409 LEVEL II HEMATOLOGY TESTS Ancillary No pay as normal zero payment    
410 URINALYSIS Ancillary Yes package as normal payment reduction    
411 BLOOD AND URINE DIPSTICK TESTS Ancillary Yes package as normal payment reduction    
412 MINOR PULMONARY TESTS AND SERVICES Ancillary Yes package as normal payment reduction    
470 OBSTETRICAL ULTRASOUND Ancillary No pay as normal zero payment    
471 LEVEL I CONVENTIONAL RADIOLOGY Ancillary Yes package as normal payment reduction    
472 ULTRASOUND GUIDANCE Ancillary No pay as normal zero payment 1/1/2020  
473 CT GUIDANCE Ancillary No pay as normal zero payment 1/1/2020  
474 RADIOLOGICAL GUIDANCE FOR THERAPEUTIC OR DIAGNOSTIC PROCEDURES Ancillary No pay as normal zero payment 1/1/2020  
475 MRI GUIDANCE Ancillary No pay as normal zero payment 1/1/2020  
486 LEVEL I BLOOD AND TISSUE TYPING TESTS Ancillary No package as normal payment reduction    
499 BLOOD PROCESSING, STORAGE AND RELATED SERVICES Ancillary No pay as normal zero payment 1/1/2020