Wednesday, June 9, 2010

modifier GC, GN, GO, GP, GT and GE - Teleconsultations and speech language

Teaching Physician Modifiers

GC     This service has been performed in part by a resident under the direction of a teaching physician.

GE      This service has been performed by a resident without the presence of a teaching physician under the primary care exception.


Modifier GC Correct Use

    Append to service that has been completed by a resident in a teaching facility in part under direction and supervision of a teaching physician

        Medicare does not pay for any service furnished by a medical student as defined in Internet Only Manual (IOM), Claims Processing Manual 100-04, Chapter 12, Section 100 This link takes you to an external website..

    Append in second modifier field when supervising/teaching anesthesiologist is involved in two concurrent anesthesia cases with one resident (or "fellow"), he/she may bill usual base units and anesthesia time for amount of time present with resident throughout pre, intra and post anesthesia care.

Incorrect Use

    Append to service when teaching physician is not involved with any part of care

Teaching Physician Documentation

Teaching physicians shall personally document that they performed the service or were physically present during key or critical portions of the service and their participation in the management of the patient. The physician is able to refer to the resident's documentation; however, a statement by the attending (teaching) physician is required and must include essential and independent documentation to tie into the resident's documentation. Without such documentation, no reimbursement can be made.

Examples:

    Acceptable

        Patient became hypoxic and hypotensive. I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs and oxygen. I reviewed the resident's assessment and plan of care.

    Unacceptable

        I saw the patient and agree with the resident.

NOTE: In a time based setting, such as critical care, time spent teaching does not count towards the critical care time of the physician; nor does the time the resident spent with the patient. Only time spent together with the patient or the teaching physician alone can be counted towards critical care time.


Teleconsultations Modifiers

GQ    Via asynchronous telecommunications system
GT     Via interactive audio and video telecommunication systems.


Speech-Language Pathologist Modifer

GN    Services delivered under an outpatient speech language pathology plan of care.

Correct Use

    Submit modifier GN to indicate that the services were delivered under an outpatient speech language pathology plan of care.
    If additional modifiers are required with the service, modifier GN must be submitted in the first or second modifier position.
    Exception:  Claims from physicians (all specialty codes) and non-physician practitioners, including specialty codes "50, 89, and 97", may be processed without therapy modifiers for sometimes only therapy codes.
    If specialty codes "65" and "67" are on the claim and an applicable HCPCS code is without one of the therapy modifiers (GN, GO, GP), the claim will be returned as unprocessable.

Discipline Specific Outpatient Rehabilitation Modifiers - All Claims


Modifiers are used to identify therapy services whether or not financial limitations are in effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes except as noted in §20 of this chapter. Consult §20 for the list of codes to which modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform.

The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:

• GN Services delivered under an outpatient speech-language pathology plan of care;

• GO Services delivered under an outpatient occupational therapy plan of care; or,

• GP Services delivered under an outpatient physical therapy plan of care.

This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech-language pathology or occupational therapy services as noted on the applicable code list in §20 of this chapter.


Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech-language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers.

Contractors edit institutional claims to ensure the following:

• that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X.

• that no more than one GN, GO or GP modifier is reported on the same service line.

• that revenue codes and modifiers are reported only in the following combinations:

o Revenue code 42x (physical therapy) lines may only contain modifier GP

o Revenue code 43x (occupational therapy) lines may only contain modifier GO

o Revenue code 44x (speech-language pathology) lines may only contain modifier GN.

• that discipline-specific evaluation and re-evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation).

Contractors return to the provider institutional claims that do not meet one or more of these conditions.

Modifier GO Services delivered under an outpatient occupational therapy plan of care

Correct Use

    Submit this modifier with services that were delivered under an outpatient occupational therapy plan of care.
    If additional modifiers are required with the service, HCPCS modifier GO must be submitted in the first or second modifier position.




Modifier GP Services delivered under an outpatient physical therapy plan of care

Correct Use

    Submit this modifier with services that were delivered under an outpatient physical therapy plan of care.
    If additional modifiers are required with the service, modifier GP must be submitted in the first or second modifier position.



Using with HCPCS codes

Some HCPCS/CPT codes that are not on the list of therapy services should not be billed with a modifier. For example, outpatient non-rehabilitation HCPCS codes G0237, G0238, and G0239 should be billed without therapy modifiers. These HCPCS codes describe services for the improvement of respiratory function and may represent either “incident to” services or respiratory therapy services that may be appropriately billed in the CORF setting. When the services described by these G-codes are provided by physical therapists (PTs) or occupational therapists (OTs) treating respiratory  conditions,

they are considered therapy services and must meet the other conditions for physical and occupational therapy. The PT or OT would use the appropriate HCPCS/CPT code(s) in the 97000 - 97799 series and the corresponding therapy modifier, GP or GO, must be used.

Another example of codes that are not on the list of therapy services and should not be billed with a therapy modifier includes the following HCPCS codes: 95860, 95861, 95863, 95864, 95867, 95869, 95870, 95900, 95903, 95904, and 95934. These services represent diagnostic services - not therapy services; they must be appropriately billed and shall not include therapy modifiers.

Other codes not on the therapy code list, and not paid under another fee schedule, are appropriately billed with therapy modifiers when the services are furnished by therapists or provided under a therapy plan of care and where the services are covered and appropriately delivered (e.g., the therapist is qualified to provide the service). One example of non-listed codes where a therapy modifier is indicated regards the provision of services described in the CPT code series, 29000 through 29590, for the application of casts and strapping. Some of these codes previously appeared on the therapy code list, but were deleted because we determined that they represented services that are most often performed outside a therapy plan of care. However, when these services are provided by therapists or as an integral part of a therapy plan of care, the CPT code must be accompanied with the appropriate therapy modifier.

NOTE: The above lists of HCPCS/CPT codes are intended to facilitate the contractor’s ability to pay claims under the MPFS. It is not intended to be an exhaustive list of covered services, imply applicability to provider settings, and does not assure coverage of these services.

Modifiers are used to identify therapy services whether or not financial limitations are in effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes except as noted in §20 of this chapter. Consult §20 for the list of codes to which modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform.

The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:

• GN Services delivered under an outpatient speech-language pathology plan of care;
• GO Services delivered under an outpatient occupational therapy plan of care; or,
• GP Services delivered under an outpatient physical therapy plan of care.

This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech-language pathology or occupational therapy services as noted on the applicable code list in §20 of this chapter.

Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech-language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers. Contractors edit institutional claims to ensure the following:

• that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X.
• that no more than one GN, GO or GP modifier is reported on the same service line.
• that revenue codes and modifiers are reported only in the following combinations:
o Revenue code 42x (physical therapy) lines may only contain modifier GP
o Revenue code 43x (occupational therapy) lines may only contain modifier GO
o Revenue code 44x (speech-language pathology) lines may only contain modifier GN.
• that discipline-specific evaluation and re-evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation). Contractors return to the provider institutional claims that do not meet one or more of these conditions.

The codes that are allowed one unit for “Allowed Units” in the chart below may be billed no more than once per provider, per discipline, per date of service, per patient. The codes allowed 0 units in the column for “Allowed Units”, may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP). When physicians/NPPs bill “always therapy” codes they must follow the policies of the type of therapy they are providing e.g., utilize a plan of care, bill with the appropriate

therapy modifier (GP, GO, GN), bill the allowed units on the chart below for PT, OT or SLP depending on the plan. A physician/NPP shall not bill an “always therapy” code unless the service is provided under a therapy plan of care. Therefore, NA stands for “Not Applicable” in the chart below.

When a “sometimes therapy” code is billed by a physician/NPP, but as a medical service, and not under a therapy plan of care, the therapy modifier shall not be used, but the number of units billed must not exceed the number of units indicated in the chart below per patient, per provider/supplier, per day.

NOTE: As of April 1, 2017, the chart below uses the CPT Consumer Friendly Code Descriptions which are intended only to assist the reader in identifying the service related to the CPT/HCPCS code. The reader is reminded that these descriptions cannot be used in place of the CPT long descriptions which officially define each of the services. The table below no longer contains a column noting whether a code is “timed” or “untimed” as this notation is not relevant to the number of units allowed per code on claims for the listed therapy services. We note that the official long descriptors for the CPT codes can be found in the latest CPT code book.


Non-covered Charge Reporting

(Rev. 1921, Issued: 02-19-10, Effective: 04-01-10, Implementation: 04-05-10) Institutional outpatient therapy claims may report non-covered charges when appropriate according to the instructions provided in of this manual. Outpatient therapies billed as non-covered charges are not counted toward the financial limitation described above, when that limitation is in effect, unless the charges are subject to review after they are submitted and found to be covered by Medicare. Modifiers associated with non-covered charges that are presented in Chapter 1, section 60 can be used on claim lines for therapy services, in addition to the use of modifiers -GN, -GO and -GP

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