Modifiers to AMCC Tests Submitted for ESRD Patients

The ESRD 50/50 rule requires the billing laboratory to determine (for the same beneficiary on the same date-of-service):

• The number of AMCC tests (ordered and performed) that are included in the composite payment rate paid to the ESRD facility (or the monthly capitation payment made to the furnishing physician)
• The number of covered non-composite tests paid.

The proportion of composite versus non-composite tests calculated by the billing laboratory is then used to determine whether separate payment may be made for all tests performed on that day.

Effective January 1, 2006, when billing for AMCC tests for an ESRD patient, the laboratory must identify the appropriate modifier for each test, as follows:

• Modifier “CD” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is part of the composite rate and is not separately billable.
• Modifier “CE” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity.
• Modifier “CF” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is not part of the composite rate and is separately billable.