Beneficiary Requested Upgrade for ABN, more than 4 Modifiers on a Claim
ABN Required; if service denied in development, beneficiary assumed liable
Use only on line items requiring more than [2 or ] 4* modifiers on home health DME claims (TOBs 32x, 33x, 34x)
Line item submitted as covered, claim must suspend for development
Modifier-QL
Patient pronounced dead after ambulance called
None, recommend documenting records; provider liable
Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x)
Mileage lines submitted as non-covered and will be denied; base rate line submitted covered
Modifier-TQ
Basic life support transport by a volunteer ambulance provider
Not payable by Medicare
None, recommend documenting records; provider liable
Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x)
Lines submitted as non-covered and will be denied
Modifier -TS
Follow-Up Service
Not payable by Medicare
No notice requirement, unless COPs require, recommend documenting records; beneficiary liable
Use on all types of provider claims when services are billed as non-covered for reasons other than can be established with other coding/modifiers (i.e., -GY) when the beneficiary is liable for other documented reasons. May be used in association with modifier –GX.
Lines submitted as non-covered and will be denied
NOTE: Many provider systems will not allow the submission of more than two modifiers. In such cases, despite the official definition and the capacity of the Medicare systems to take in five modifiers on a line with direct EDI submission, contractors processing home health claims should educate that it is appropriate to use this modifier when three modifiers are needed if there is a two-modifier limit.
All modifiers listed in the chart immediately above need to be used only when non-covered services cannot be split to entirely non-covered claims. Modifiers indicating provider liability cannot be used on entirely no payment claims for which the beneficiary has liability. Inappropriate use of these modifiers may result in entire claims being returned to providers.
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