SG modifier definition and appropriate use

Modifier SG Fact Sheet

Definition:

• Services Performed at an Ambulatory Surgical Center* (ASC) facility

Appropriate Use:

• Do not use for dates of service January 1, 2008 and after.

• Use on claims for the ASC facility services.

• Claims must be submitted as assigned claims.

• Place of service must be 24.

• Report the appropriate Procedure code for the procedure(s) performed.

• Use the appropriate modifier. Modifiers direct prompt and correct payment of the claims submitted.

Bill documentation modifiers in the first modifier field.

• List the specialty 49 provider number in item 33 or the electronic equivalent.

Facts:

Refer to Policy ASC-001, Ambulatory Surgical Centers (ASCs) for more specific information relating to ASC services.


Ambulatory Surgery Center Billing Guidelines



The ASC fee schedule is modeled after the Outpatient Prospective Payment System (OPPS). ASC rules for modifier 50/51 application are different from Procedure  standard.

When submitting a claim for multiple procedures, submit the primary procedure as the first procedure code. Use modifier 51 in the first modifier position and subsequent procedures including exempt and add on codes. If modifier 51 is missing on secondary and subsequent procedures that should be stepped down, Insurance may deny the claim as billed in error and request a correction or a modifier 51 to be appended to indicate multiple procedures.

Note: Insurance requires the use of Modifier SG to expedite processing.


 Procedure         Billed         Contract Allowed           Modifier          Considered Allowed


31255-SG-RT $1,500.00 $1,100.00 0% $1,100.00

31255-51-SG-LT $1,500.00 $1,100.00 X 50% $550.00

30520-51-SG $1,000.00 $900.00 X 50% $450.00

30140-51-SG-RT $600.00 $450.00 X 50% $225.00

30140-51-SG-LT $600.00 $450.00 X 50% $225.00


For this example, the primary procedure is 31255-RT and allowed at 100% of the fee schedule allowance, or billed charges, whichever is less. All remaining procedures are allowed at 50 percent of the fee schedule allowance.



When submitting a claim for multiple procedures, submit the primary procedure as the first procedure code. Use modifier 51 in the first modifier position and subsequent procedures including exempt and add on codes. If modifier 51 is missing on secondary and subsequent procedures that should be stepped down, Insurance may deny the claim as billed in error and request a correction or a modifier 51 to be appended to indicate multiple procedures.

Note: Insurance requires the use of Modifier SG to expedite processing.


Procedure             Billed           Contract Allowed           Modifier          Considered Allowed


31255-RT $1,500.00 $1,100.00 100% $1,100.00

31255-51-LT $1,500.00 $1,100.00 X 50% $550.00

30520-51 $1,000.00 $900.00 X 25% $225.00

30140-51-RT $600.00 $450.00 X 25% $112.50

30140-51-LT $600.00 $450.00 X 25% $112.50

Note: For ASCS claims, Insurance does not recognize Add-on Codes and procedures not subject to the MPR guidelines. All procedures are eligible for MPR.