CurrentUCarePolicy N/A

Use of HCPCS modifier -PN for nonexcepted off-campus outpatient provider-based departments

Defines UCare's billing and reimbursement requirements for services furnished in nonexcepted off‑campus outpatient provider‑based departments of hospitals, including when to append HCPCS modifier -PN and resulting payment adjustment. Applies to all UCare products.

Policy Summary

PayerUCare

PolicyUse of HCPCS modifier -PN for nonexcepted off-campus outpatient provider-based departments

Policy CodePolicy N/A

Change TypeNo material change

Effective Date1/1/2020

Next Review DateN/A

Key ActionAppend HCPCS modifier -PN to all nonexcepted outpatient hospital claim lines furnished in off‑campus provider‑based departments; do not append -PN to excepted items or services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40%reimbursement rate when -PN appended

1/1/2020effective date of the 40% reimbursement adjustment

Policy at a Glance

This policy defines UCare's billing and reimbursement requirements for services furnished in nonexcepted off‑campus outpatient provider‑based departments of hospitals. It applies to all UCare products and requires providers to append the HCPCS -PN modifier on every HCPCS code for outpatient hospital items and services furnished in a nonexcepted off‑campus provider‑based department. Effective 1/1/2020, reimbursement for services with the -PN modifier is adjusted to 40% of the product‑specific hospital outpatient payment rate for services assigned to the listed APC status indicators. Status: CURRENT (last reviewed 2025-03-04).

Policy statistics

reimbursement rate when -PN appended40%

effective date of the 40% reimbursement adjustment1/1/2020

When to Append HCPCS Modifier -PN

When to append -PN modifier

Rules governing use of HCPCS modifier -PN for off-campus provider-based department services.

Policy Summary

PayerUCare

PolicyUse of HCPCS modifier -PN for nonexcepted off-campus outpatient provider-based departments

Policy CodePolicy N/A

Change TypeNo material change

Effective Date1/1/2020

Next Review DateN/A

Key ActionAppend HCPCS modifier -PN to all nonexcepted outpatient hospital claim lines furnished in off‑campus provider‑based departments; do not append -PN to excepted items or services.

SourceLink

On This Page

ALL of the following

Service is furnished in an off‑campus outpatient provider‑based department of a hospital
The service is nonexcepted (not one of the CMS-defined excepted items/services)

ANY of the following

If a claim contains both excepted and nonexcepted items/services, append -PN only to the nonexcepted claim lines

Reimbursement adjustment40% of product-specific hospital outpatient payment rate for services assigned to listed APC status indicators

APC Status Indicators & Modifiers

APC status indicators affectedmixed

J1	Hospital Part B services paid through a comprehensive APC
J2	Hospital Part B services that may be paid through a Comprehensive APC (Observation)
Q1	STV-packaged codes
Q2	T-packaged codes
Q3	Codes that may be paid through a composite APC
S	Procedure or Service, Not Discounted when multiple
T	Procedure or Service, Multiple Procedure Reduction Applies
V	Clinic Visit

ModifierModifierCovered

-PN	Nonexcepted service provided at an off‑campus outpatient provider‑based department

Billing & Documentation Requirements

Billing Rule

Append -PN modifier

Append HCPCS modifier -PN to every HCPCS code for outpatient hospital items and services furnished in a nonexcepted off‑campus provider‑based department. Do not append -PN to excepted items/services; if a claim includes both excepted and nonexcepted services, use -PN only on the nonexcepted claim lines.

Documentation Required

Follow Medicare guidance for -PN use

UCare follows Medicare guidance for submission and use of the -PN modifier; providers must follow CMS documentation and billing guidance referenced in the Additional Links.

Follow CMS documentation and billing guidance referenced in Additional Links

Clinical / Administrative Background

Background: UCare follows Medicare guidance on the use and submission of the -PN modifier for off‑campus provider‑based department services. Applicable CMS and MLN guidance and regulations inform which services are considered excepted vs nonexcepted and how claims must be reported; key CMS resources are listed below.

Key Terms

Definitions

-PN modifierModifier indicating a nonexcepted service provided at an off‑campus outpatient provider‑based department of a hospital.

Nonexcepted serviceAn outpatient hospital service furnished at an off‑campus provider‑based department that is not listed as an excepted service under CMS rules (excepted items/services should not be reported with -PN).

APC status indicatorAmbulatory Payment Classification status indicators that determine payment categorization for hospital outpatient services (examples: J1, J2, Q1, Q2, Q3, S, T, V).

Primary References

References: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 4, section 20.6.12; MLN Matters SE18002 (Effective 1/1/2017); MLN Matters MM9930 (12/22/2016); SE19007 Revised (2/5/2024) and MLN Matters MM11099 Revised (2/18/2019); 42 CFR 413.65 (provider‑based clinics).

Document Dates & Review

Policy dates: Effective 1/1/2020; Last review completed 2025-03-04. No next review date is scheduled. There has been no material change to this policy since the prior review.