Showing posts with label cpt modfiers. Show all posts
Showing posts with label cpt modfiers. Show all posts

Monday, February 17, 2020

Post operative period billing guidelines - Modifier usage


POST-OPERATIVE PERIOD BILLING

Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure. These modifiers are:

Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period).

The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.

Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure. Special Reporting for Certain Practitioners for CPT code 99024 Practitioners are required to report post-operative E/M visits using CPT code 99024 if they:

• Practice in one of the following nine states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, or Rhode Island; and

• Practice in a group of ten or more practitioners;

• Practitioners who only practice in practices with fewer than 10 practitioners are exempted from required reporting, but are encouraged to report if feasible and,

• Provide global services under one of the required procedure codes. The required procedure codes are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges.

The term “practitioner” is used to refer to both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries (see 81 FR 80172). This  reporting is required for post-operative visits during the global period for procedures with dates of service on or after July 1, 2017. For more information, see Claims-Based Reporting Requirements for Post-Operative Visits. Codes for Which Reporting on Post-Operative Visits is Required As of January 1, 2018, there are some changes made to the list of codes for which reporting is required.

These changes are made necessary by changes in the coding system.

The following CPT codes no longer need to be reported: CPT codes 15732, 34802, and 34825 are deleted. Reporting is not required after December 31, 2017.


CPT codes 30140, 36470, and 36471 have a 0-day global period so reporting is not needed.

The Codes for Required Global Surgery Reporting (CY 2018) [ZIP, 20KB] shows the codes for which reporting is required on or after January 1, 2018.

Return to the OR for a Related Procedure during the Post-Operative Period

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the physician should use the unspecified procedure code in the correct series, which is, 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier “-78” (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period).  The physician may also need to indicate that another procedure was performed during the post-operative period  of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

NOTE: The CPT definition for modifier “-78” does not limit its use to treatment for complications.

Staged or Related Procedure or Service by the Same Physician During the Post-operative Period Modifier “-58” (Staged or related procedure or service by the same physician during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the post-operative period of the first procedure. Modifier “-58” indicates that the performance of a procedure or service during the post-operative period was:
• Planned prospectively or at the time of the original procedure
• More extensive than the original procedure
• For therapy following a diagnostic surgical procedure Modifier “-58” may be reported with the staged procedure’s CPT. A new post-operative period begins when the next procedure in the series is billed.

Critical Care

Critical care services furnished during a global surgical period for a seriously injured or burned patient are not considered related to a surgical procedure and may be paid separately under the following circumstances. Pre-operative and post-operative critical care may be paid in addition to a global fee if:
• The patient is critically ill and requires the constant attendance of the physician; and
• The critical care is above and beyond, and, in most instances, unrelated to the specific anatomic injury or general surgical procedure performed.


Special Reporting for Certain Practitioners for CPT code 99024

Practitioners are required to report post-operative E/M visits using CPT code 99024 if they:

• Practice in one of the following nine states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, or Rhode Island; and
• Practice in a group of ten or more practitioners;
• Practitioners who only practice in practices with fewer than 10 practitioners are exempted from required reporting, but are encouraged to report if feasible and,
• Provide global services under one of the required procedure codes. The required procedure codes are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges.

The term “practitioner” is used to refer to both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries (see 81 FR 80172). This reporting is required for post-operative visits during the global period for procedures with dates of service on or after July 1, 2017

Return to the OR for a Related Procedure during the Post-Operative Period

When treatment for complications requires a return trip to the operating room, physicians bill the CPT code that describes the procedure(s) performed during the return trip. If no such code exists, the physician should use the unspecified procedure code in the correct series, which is, 47999 or 64999. The procedure code for the original surgery is not used except when the identical procedure is repeated.

In addition to the CPT code, physicians report modifier “-78” (Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the post-operative period). The physician may also need to indicate that another procedure was performed during the post-operative period of the initial procedure. When this subsequent procedure is related to the first procedure, and requires the use of the operating room, this circumstance may be reported by adding the modifier “-78” to the related procedure.

NOTE: The CPT definition for modifier “-78” does not limit its use to treatment for complications.

Tuesday, October 8, 2019

Modifier UB, UC, UA - Billing Guidelines

Modifier  Description
UB Medically necessary delivery prior to 39 weeks of gestation
UC Delivery at 39 weeks of gestation or later
UA Nonmedically necessary delivery prior to 39 weeks of gestation

EED Policy Components

•  GAMMIS is being configured to link practitioners’ induction and delivery claims to the hospital’s induction and delivery claims

•  Induction and delivery claims that are submitted with medical conditions that do not warrant an exception for an induction or delivery prior to 39 weeks gestation will deny payment

•  For non-medically necessary deliveries:–  The practitioner’s claim will fully deny–  The hospital’s claim will deny for the induction and/or delivery portion

•  Practitioners and hospitals may submit an appeal for the denial (DMA 520-A form) to the DCH Medicaid peer review organization, Georgia Medical Care Foundation

•  Compliance will be monitored by DCH and the Centers for Medicare and Medicaid Services through Georgia’s reporting of the Early Elective Deliveries measure 14 found in the Initial Core Set of Health Quality Measures for Medicaid Eligible Adults

•  These specifications contain the same exclusions as the JCAHO list of exclusions•  CY 12 data will serve as the baseline for this CMS measure


Purpose of EED Policy

•  Guide providers and hospitals to sound practice recommendations made by ACOG and others
•  Reduce morbidity in neonates from birth trauma and fetal immaturity
•  Reduce non-medically necessary deliveries less than 39 weeks gestation
•  Encourage greater collaborations between hospitals and their physicians in developing quality improvement initiatives aimed at improving birth outcomes

Modifier/condition codes needed for maternity services/obstetric delivery - Unicare insurance billing


This provider bulletin is an update to information in the provider manual. For access to the latest manual, go to www.UniCare.com.West Virginia is ranked 44thby America’s Health Rankings for infant mortality; nearly eight (7.4) of every 1,000 children die before their first birthday. Infant mortality is a multi factorial health problem, and improving West Virginia’s infant mortality rate will require a multifaceted approach. One of the approaches of UniCare Health Plan of West Virginia, Inc. (UniCare)is to reduce early elective deliveries (EEDs) prior to 39 weeks of gestation. The initiative of reducing EEDs has received national attention from many organizations, including the Centers for Medicare & Medicaid Services (CMS), the March of Dimes, the American Congress of Obstetricians and Gynecologists (ACOG), and The Joint Commission.

Additionally, many West Virginia hospitals and their medical staffs have responded to this initiative by adopting policies that ensure early inductions and cesarean deliveries are medically necessary. UniCare is aligning its obstetric services policy with the goal of improving neonatal and maternal health outcomes. Deliveries that occur prior to 39 weeks, either due to spontaneous labor or as the result of a medically-indicated induction or cesarean section, will continue to remain covered; however,for claims to pay, a modifier or condition code is needed. Deliveries prior to 39 weeks, unless documented as a medical necessity or spontaneous labor, are not a covered benefit.

* Effective for dates of service on or after October 1, 2016,UniCare will require the above modifiers to be used when submitting a claim,or the claim will deny.

Effective for dates of admission on or after October 1, 2016, the following condition codes will be required on the CMS1450 (UB-04)claim form when billing for obstetric delivery services. Condition codes are to be placed in fields 18-24 of theCMS1450 (UB-04)claim form.

Condition code  Description

81 Cesarean sections or inductions performed at less than 39 weeks’ gestation for medical necessity

82 Cesarean sections or inductions performed at less than 39 weeks’ gestation electively

83 Cesarean sections or inductions performed at 39 weeks’ gestation or greater



 Coding for Maternity Care - Medicaid Guidelines

Gestational Age


Providers are required to report the gestational age of the fetus by using the appropriate ICD-10 diagnosis codes Z3A.00 through Z3A.49 on all delivery claims.

Modifier UC

Providers are required to append modifier UC on claims of deliveries 39 weeks or less that are medically necessary or on deliveries 39 weeks or more, whether spontaneous or elective.  If the modifier “UC” is not appended to the claim, it is understood that the claim was for an early elective delivery less than 39 weeks and 0 days and will be denied.  Providers are responsible for ensuring that the codes (and modifiers when applicable) submitted for reimbursement accurately
reflect the diagnosis and procedure(s) reported.

Modifier 22

All obstetrical and delivery procedure codes submitted with modifier 22 require submission of documentation (e.g., operative report) for review prior to payment.  Services for enhanced payment with the 22 modifier include multiple gestations or complications during the delivery which place the mother or fetus at risk of adverse outcome.


Tuesday, January 24, 2017

Modifier CC, CG, CT, CS - Definition and Usage

Modifier CC - Procedure Code Change No impact on percentage

Procedure codes reported with modifier CC indicate that a corrected claim has beensubmitted, usually in response to a previously rejected claim. Claims history will be researched to determine the correct adjudication of the claim.

[This modifier is used when the submitted procedure code is changed either for administrative reasons or  because an incorrect code was filed.]

BU THE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND AFTER 30 DAYS HAS NOT INFORMED THE SUPPLIER OF HIS/HER DECISION CC PROCEDURE CODE CHANGE (USE 'CC' WHEN THE PROCEDURE CODE SUBMITTED WAS CHANGED EITHER FOR ADMINISTRATIVE REASONS OR BECAUSE AN INCORRECT CODE WAS FILED). (SUPPLIERS SHOULD NOT SUBMIT MODIFIER CC.)

CG POLICY CRITERIA APPLIED (EFFECTIVE DATE 07/01/2008)

CR CATASTROPHE/DISASTER RELATED

CS ITEM OR SERVICE RELATED, IN WHOLE OR IN PART, TO AN ILLNESS, INJURY, OR CONDITION THAT WAS CAUSED BY OR EXACERBATED BY THE EFFECTS, DIRECT OR INDIRECT, OF THE 2010 OIL SPILL IN THE GULF OF MEXICO, INCLUDING BUT NOT LIMITED TO, SUBSEQUENT CLEAN-UP ACTIVITIES (EFFECTIVE 04/20/2010)


Codes for CC Modifier

Partial Quantity  Code Description

A4216 STERILE WATER, SALINE AND/OR DEXTROSE

A4217 STERILE WATER/SALINE, 500 ML

A4218 STERILE SALINE OR WATER

A4221 SUPPLIES FOR MAINTENANCE DRUG INFUS CATH

A4244 ALCOHOL OR PEROXIDE, PER PINT

A4245 ALCOHOL WIPES, EACH

A4246 BETADINE SOLUTION,PER PINT

A4247 BETADINE OR IODINE SWABS/WIPES, (EACH)

A4248 CHLORHEXIDINE CONTAINING ANTISEPTIC, 1 M

A4250 URINE TEST/REAGENT STRP/TABS,100

A4253 BLOOD GLUCOSE STRIPS/50

A4255 PLATFORMS FOR HOME GLUCOSE MON. 50/BOX

A4259 LANCETS, PER 100

A4265 PARAFIN

A4364 OSTOMY SKIN BOND OR CEMENT, PER OUNCE

A4369 OSTOMY SKIN BARRIER, LIQUID PER OZ

A4371 OSTOMY SKIN BARRIER, POWDER PER OZ

A4394 OST. DEODERANT FOR USE IN POUCH, LIQUID

A4402 OSTOMY LUBRICANT (EACH)

A4405 OSTOMY SKIN BARRIER NON-PECTIN PASTE

A4406 OSTOMY SKIN BARRIER, PECTIN BASED

A4450 TAPE,NON-WATERPROOF,PER 18 INCHES

A4452 TAPE WATERPROOF, PER 18 INCHES

A4455 ADHESIVE REMOVER OR SOLVENT (TAPE, CEMEN

A4556 ELECTRODES, (E.G. APNEA MONITOR)

A4557 LEAD WIRES, (E.G. APNEA MONITOR)

A4558 CONDUCTIVE PASTE OR GEL


SUBJECT: Payment Reduction for Computed Tomography (CT) Diagnostic Imaging Services

I. SUMMARY OF CHANGES: Effective January 1, 2016, a payment reduction of 5 percent applies to Computed Tomography (CT) services furnished using equipment that is inconsistent with the CT equipment standard and for which payment is made under the physician fee schedule. The payment reduction increases to 15 percent in 2017 and subsequent years.

EFFECTIVE DATE: January 1, 2016

*Unless otherwise specified, the effective date is the date of service.

IMPLEMENTATION DATE: January 4, 2016

Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)

R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D CHAPTER / SECTION / SUBSECTION / TITLE

R 12/TOC

N 12/20.4.7 - Services That Do Not Meet the National Electrical Manufacturers

Association (NEMA) Standard XR-29-2013


III. FUNDING:

For Medicare Administrative Contractors (MACs):

The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

V. ATTACHMENTS:
Business Requirements

Manual Instruction
Attachment - Business Requirements

Pub. 100-04 Transmittal: 3402 Date: November 6, 2015 Change Request: 9250 NOTE: This Transmittal is no longer sensitive and is being re-communicated. This instruction may now be posted to the Internet.

Transmittal 3299, dated August 6, 2015, is being rescinded and replaced by Transmittal 3402, dated November 6, 2015, to remove MCS from requirement 9250.5 and because the CR is no longer “sensitive/controversial.” All other information remains the same.


SUBJECT: Payment Reduction for Computed Tomography (CT) Diagnostic Imaging Services EFFECTIVE DATE: January 1, 2016
*Unless otherwise specified, the effective date is the date of service.

IMPLEMENTATION DATE: January 4, 2016


I. GENERAL INFORMATION

A. Background: Section 218(a) of the Protecting Access to Medicare Act of 2014 (PAMA) is titled “Quality Incentives To Promote Patient Safety and Public Health in Computed Tomography Diagnostic Imaging.” It amends the Social Security Act (SSA) by reducing payment for the technical component (and the technical component of the global fee) of the Physician Fee Schedule service (5 percent in 2016 and 15 percent in 2017 and subsequent years) for computed tomography (CT) services identified by CPT codes 70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, and 75571-75574 furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013, entitled “Standard Attributes on CT Equipment Related to Dose Optimization and Management.”

The statutory provision requires that information be provided and attested to by a supplier and a hospital outpatient department that indicates whether an applicable CT service was furnished that was not consistent with the NEMA CT equipment standard, and that such information may be included on a claim and may be a modifier. The statutory provision also provides that such information shall be verified, as appropriate, as part of the periodic accreditation of suppliers under SSA section 1834(e) and hospitals under SSA section 1865(a). Any reduced expenditures resulting from this provision are not budget neutral. To implement this provision, the Centers for Medicare and Medicaid Services (CMS) will create modifier “CT” (Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard). Beginning in 2016, claims for CT scans described by above-listed CPT codes (and any successor codes) that are furnished on non-NEMA Standard XR-29-2013-compliant CT scans must include modifier “CT” that will result in the applicable payment reduction.

B. Policy: Beginning January 1, 2016, a payment reduction of 5 percent applies to the technical component (and the technical component of the global fee) for Computed Tomography (CT) services furnished using equipment that is inconsistent with the CT equipment standard and for which payment is made under the physician fee schedule. This payment reduction becomes 15 percent for 2017 and succeeding years.

Background

The Protecting Access to Medicare Act (H.R. 4302; P.L. 113-93), also known as PAMA, enacted in 2014, amended the Social Security Act (the Act) to extend Medicare payments to physicians and other providers of the Medicare and Medicaid program.

Section 218(a) of the Protecting Access to Medicare Act (PAMA) requires that ADI suppliers and hospital outpatient areas providing CT services must meet safety requirements under NEMA Standard XR-29-2013 beginning on January 1, 2016. ADI suppliers and hospital outpatient departments that are non-compliant with these safety requirements must use a Current Procedural Terminology (CPT) code modifier on their Medicare billing to attest to non-compliance. These non-compliant ADI suppliers will receive a decrease in their Medicare payment of 5% in 2016 with a further reduction to 15% in 2017 and thereafter.

Memorandum Summary

• Information Only: The Centers for Medicare & Medicaid Services (CMS) is sharing this clarification with State and Federal Surveyors as information only. Surveyors will not be expected to determine compliance with Advanced Diagnostic Imaging (ADI) suppliers or hospital outpatient department requirements. Accrediting Organizations (AOs) will be evaluating compliance on a periodic basis. State Agency and Regional Office Staffs have no role to play in this process.

• Clarifications: The CMS is providing compliance and payment clarifications based on stakeholder questions regarding National Electrical Manufacturers Association (NEMA) XR-29 Standard.

• Frequently Asked Questions (FAQs): The FAQs attached with this policy memorandum aim to clarify stakeholder uncertainty and to include aspects of payment reductions if CT systems are found non-compliant.



Clarification

In late 2015, stakeholders which included radiologists, hospital administrators, medical physicists, and individual institutions raised concern regarding the uncertainty of determination and documentation of compliance to the NEMA XR-29 “Standard Attributes on CT Equipment Related to Dose Optimization and Management” (MITA SmartDose) Standard.

Additionally, third party vendor claims of “XR-29 Solutions” may or may not actually upgrade a CT scanner to full compliance within the law has raised concern among the health care industry.

Therefore, CMS has compiled the attached FAQ document to clarify reimbursement changes for non-compliant systems and information regarding billing, coding and payment rates.

Effective Date: This memorandum is provided as information only. If providers have questions about this topic, they should be referred to this email box: [email protected]

Wednesday, November 23, 2016

Surgery Modifier code list

Modifiers Pertaining to Surgery or Services within the Global Period Modifiers assure that the carrier will give  consideration to the special circumstances that may affect payment. Omitting modifiers may result in payment denials. If a review is requested on a denied service, the appropriate modifier must be included with the review. A description of the service will not be sufficient to change the original claim decision. Use of the modifiers in this section applies to both major procedures with a 90-day postoperative period and minor procedures with a 10-day postoperative period (and/or a zero day postoperative period in the case of CPT modifiers 22 and 25.

CPT Modifier 22 – Unusual Procedural Services

When the service(s) provided is greater than that usually required for the listed procedure,  it may be identified by adding CPT modifier 22 to the usual procedure number.


CPT Modifier 24 – Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period

The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the CPT modifier 24 to the appropriate level of E/M service.



CPT Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the  Procedure or Other Service




CPT Modifier 50 – Bilateral Procedure

Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session must be identified by adding the CPT modifier 50 to the appropriate five-digit code.

Note: To prevent duplicate denials, surgical procedures billed bilaterally must be reported using the surgical code and the 50 CPT modifier billed on one detail.

CPT Modifier 51 – Multiple Procedures

When multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the CPT modifier 51 to the additional procedure or service code(s).

Note: This modifier must not be appended to designated "add-on" codes. CPT Modifier 52 – Reduced Services

Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the CPT modifier 52 signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.

Note: For hospital outpatient reporting of a previously scheduled procedure and/or service that is partially reduced or cancelled as a result of extenuating  circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see CPT modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).


* Use of this modifier requires additional documentation such as an operative report and a concise statement specifying how the service differs from the usual.

* This information must be indicated in the appropriate documentation record for electronic claims or sent via FAX. It may also be attached to the  CMS-1500 claim form for paper claims.

* Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 53 – Discontinued Procedure

Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance must be reported by adding the CPT modifier 53 to the code reported by the physician for the discontinued procedure.

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the  operating suite.

* For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see CPT modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

* Use of this modifier requires additional documentation such as a statement indicating why it was medically necessary to discontinue the procedure.

* The statement must be indicated in the appropriate documentation record for electronic claims. If paper claims are submitted, the statement must appear on an attachment to the CMS-1500 claim form.

* Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 54 – Surgical Care Only

When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services must be identified by adding the CPT modifier 54 to the usual procedure number. CPT Modifier 55 – Postoperative Management Only When one physician performs the postoperative management and another physician performs the surgical procedure, the postoperative component must be identified by adding the CPT modifier 55 to the usual procedure number.

Use of this modifier requires additional documentation and includes both the number of days postoperative care is provided, and the assumed or relinquished dates of the postoperative care.

* The number of postoperative days and the assumed or relinquished dates must be indicated in the appropriate documentation record for electronic claims.

1. For paper claims, the number of postoperative days must be indicated in Item 24g and the assumed or relinquished dates must be indicated in Item 19 of the CMS-1500 claim form.

2. Failure to submit this documentation appropriately may result in the services rejected as unprocessable.

* Claims for postoperative management only should also show the surgery as the procedure code and the date of the surgery as the date of service and the number of postoperative days the patient was seen.

CPT Modifier 56 – Preoperative Management Only

When one physician performs the preoperative care and evaluation and other physician performs the surgical procedure, the preoperative component must be identified by adding the CPT modifier 56 to the usual procedure number.

CPT Modifier 57 – Decision for Surgery 

An evaluation and management service that resulted in the initial decision to perform the surgery must be identified by adding the CPT modifier 57 to the appropriate level of E/M service.

CPT Modifier 58 – Staged or Related Procedure or Service by the Same Physician during the Postoperative Period

The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for the therapy following a diagnostic surgical procedure. This circumstance must be reported by adding the CPT modifier 58 to the staged or related procedure.

Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See CPT modifier 78.




Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. CPT modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.

* This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

* When another modifier is appropriate it should be used rather than CPT modifier 59.

CPT Modifier 62 – Two Surgeons

When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon must report his/her distinct operative work by adding the CPT modifier 62 to the single definitive procedure
code.

* Each surgeon must report the co-surgery once using the same procedure code.

* If additional procedure(s), including add-on procedure(s), are performed during the same surgical session, separate code(s) may be reported without the CPT modifier 62 added.

Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the CPT modifier 80 or CPT modifier 81 added, as appropriate.



CPT Modifier 66 – Surgical Team 

Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) are carried out under the "surgical team" concept.

* Such circumstances must be identified by each participating physician with the addition of the CPT modifier 66 to the basic procedure number used for reporting services.

CPT Modifier 76 – Repeat Procedure by Same Physician The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance must be reported by adding the CPT modifier 76 to the repeated procedure/service.


CPT Modifier 77 - Repeat Procedure by Another Physician

The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation must be reported by adding CPT modifier 77 to the repeated procedure/service.

78 Return to the Operating Room for a Related Procedure During the Postoperative Period

The physician may need to indic te that another procedure was performed during the postoperative period of the initial rocedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it must be reported by adding the CPT modifier 78 to the related procedure.

* For repeat procedures on the same day, see CPT modifier 76.

CPT Modifier 79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period

The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance must be reported by using the CPT modifier 79. For repeat procedures on the same day, see CPT modifier 76.


CPT Modifier 80 – Assistant Surgeon

Surgical assistant services may be identified by adding the CPT modifier 80 to the usual procedure number(s).

* Additional documentation required with this modifier includes a statement that no qualified resident was available to perform the service, or a statement indicating that no exceptional medical circumstances exist, or a statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative
care of his/her patients.

1. If one of the above is not provided, the name and address of the hospital where the services were furnished must be indicated. * The statement must be submitted in the appropriate documentation record for electronic claims and on an attachment to the CMS-1500 claim form for paper claims.

2. The name and address of the hospital where services were furnished must be indicated in the appropriate documentation
record for electronic claims and in Item 32 of the CMS-1500 claim form for paper claims.

3. Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 81 – Minimum Assistant Surgeon

Minimum surgical assistant services are identified by adding the CPT modifier 81 to the usual procedure number.

* Additional documentation is required with this modifier and includes a statement that no qualified resident was available to perform the service, or a statement indicating that no exceptional medical circumstances exist, or a statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients.

1. If one of the above is not provided, the name and address of the hospital where the services were furnished must be indicated.

* The statement must be submitted in the appropriate documentation record for electronic claims and on an attachment to the CMS-1500 claim form for paper claims.

2. The name and address of the hospital where services were furnished must be indicated in the appropriate documentation
record for electronic claims or in Item 32 of the CMS-1500 claim form for paper claims.

3. Failure to submit this documentation appropriately may result in services rejected as unprocessable.

CPT Modifier 82 Assistant Surgeon (When Qualified Resident Surgeon is not Available)

The unavailability of a qualified resident surgeon is a prerequisite for use of CPT modifier 82 appended to the usual procedure code number(s).


CPT Modifier 99 – Multiple Modifiers

Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations, CPT modifier 99 must be added to the basic procedure, and other applicable modifiers must be listed as part of the description of the service.

HCPCS Modifier AS – Assistant At Surgery

Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery are identified by adding the HCPCS modifier AS to the usual procedure code number.

* Additional documentation is required with this modifier and includes a statement that no qualified resident was available to perform the service, or a statement indicating that no exceptional medical circumstances exist, or a statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients.

1. If one of the above is not provided, the name and address of the hospital where the services were furnished must be indicated.


* The statement must be submitted in the appropriate documentation record for electronic claims or on an attachment to the CMS-1500 claim form for paper claims.

1. The name and address of the hospital where services were furnished must be indicated in the appropriate documentation
record for electronic claims or in Item 32 of the CMS-1500 c aim form for paper claims.

2. Failure to submit this documentation appropriately may result in services rejected as unprocessable.



Wednesday, November 16, 2016

Severity/Complexity Modifiers CH, CI , CJ , CK , CL AND CM , CN

Severity/Complexity Modifiers

For each nonpayable functional G-code, one of the modifiers listed below must be used to report the severity/complexity for that functional limitation.

Modifier                         Impairment Limitation Restriction

CH

0 percent impaired, limited or restricted

CI

At least 1 percent but less than 20 percent impaired, limited or restricted

CJ

At least 20 percent but less than 40 percent impaired, limited or restricted

CK

At least 40 percent but less than 60 percent impaired, limited or restricted

CL

At least 60 percent but less than 80 percent impaired, limited or restricted

CM

At least 80 percent but less than 100 percent impaired, limited or restricted

CN

100 percent impaired, limited or restricted


The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services.



G. Required Reporting of Functional G-codes and Severity Modifiers

The functional G-codes and severity modifiers listed above are used in the required reporting on therapy claims at certain specified points during therapy episodes of care. Claims containing these functional G-codes must also contain another billable and separately payable (non-bundled) service. Only one functional limitation shall be reported at a given time for each related therapy plan of care (POC).


Functional reporting using the G-codes and corresponding severity modifiers is required reporting on specified therapy claims. Specifically, they are required on claims:

• At the outset of a therapy episode of care (i.e., on the claim for the date of service (DOS) of the initial therapy service);

• At least once every 10 treatment days, which corresponds with the progress reporting period;

• When an evaluative procedure, including a re-evaluative one, ( HCPCS/CPT codes 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004) is furnished and billed;

• At the time of discharge from the therapy episode of care–(i.e., on the date services related to the discharge [progress] report are furnished); and

• At the time reporting of a particular functional limitation is ended in cases where the need for further therapy is
necessary.

• At the time reporting is begun for a new or different functional limitation within the same episode of care (i.e., after the reporting of the prior functional limitation is ended)

Functional reporting is required on claims throughout the entire episode of care. When the beneficiary has reached his or her goal or progress has been maximized on the initially selected functional limitation, but the need for treatment continues, reporting is required for a second functional limitation using another set of G-codes. In these situations two or more functional limitations will be reported for a beneficiary during the therapy episode of care. Thus, reporting on more than one functional limitation may be required for some beneficiaries but not simultaneously.


When the beneficiary stops coming to therapy prior to discharge, the clinician should report the functional information on the last claim. If the clinician is unaware that the beneficiary is not returning for therapy until after the last claim is submitted, the clinician cannot report the discharge status.


When functional reporting is required on a claim for therapy services, two G-codes will generally be required.


Two exceptions exist:

1. Therapy services under more than one therapy POC-- Claims may contain more than two nonpayable functional G-codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.


2. One-Time Therapy Visit-- When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider, the clinician reports on the claim for the DOS of the visit, all three G-codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers.


Each reported functional G-code must also contain the following line of service information:

• Functional severity modifier

• Therapy modifier indicating the related discipline/POC -- GP, GO or GN -- for PT, OT, and SLP services, respectively

• Date of the related therapy service

• Nominal charge, e.g., a penny, for institutional claims submitted to the A/B MACs (A). For professional claims, a zero charge is acceptable for the service line. If provider billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included.


NOTE: The KX modifier is not required on the claim line for nonpayable G-codes, but would be required with the procedure code for medically necessary therapy services furnished once the beneficiary’s annual cap has been reached.

Wednesday, November 9, 2016

Critical Access Hospital modifiers AK, GF, SB, AH and AE

Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:

• For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services. List the facility service(s) rendered to outpatients using the appropriate revenue code. The A/B MAC will pay 101 percent of the reasonable costs for the outpatient services less applicable Part B deductible and coinsurance amounts, plus:

• Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.

The A/B MAC (A) uses the Medicare Physician Fee Schedule (MPFS) amounts to pay for all the physician/nonphysician practitioner services rendered in a CAH that elected the optional method. Payment is based on the lesser of the actual charge or the facility-specific MPFS amount less deductible and coinsurance times 1.15; and

•AK - Service rendered in a CAH by a non-participating physician

For a non-participating physician service, a CAH must place modifier AK on the claim. Payment is based on the lesser of the actual charge or a reduced fee schedule amount of 95 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the non-participating physician reduction (0.95) minus (deductible and coinsurance] times 1.15.

•GF - Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA)

GF - Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA). (The “GF” modifier is not to be used for CRNA services. If a claim is received and it has the “GF” modifier for certified registered nurse anesthetist (CRNA) services, the claim is returned to the provider.) Also, while this national “GF” modifier includes CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services. Accordingly, if a claim is received and it has the “GF” modifier for CRN services, no Medicare payment should be made.

Services billed with the “GF” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15.

•SB - Services rendered in a CAH by a certified nurse-midwife

For dates of service prior to January 1, 2011, certified nurse-midwife services billed with the “SB” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 65 percent. Payment is calculated as follows:
For dates of service on or after January 1, 2011, Medicare covers the services of a certified nurse-midwife. The “SB” modifier is used to bill for the services and payment is based on the lesser of the actual charge or 100 percent of the MPFS. MPFS Payment is calculated as follows:

• [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15.

• AH - Services rendered in a CAH by a clinical psychologist

Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS. Payment is calculated as follows:

• [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15.

• AE - Services rendered in a CAH by a nutrition professional/registered dietitian.

Services billed with the “AE” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15.

Outpatient services, including ASC type services, rendered in an all-inclusive rate provider should be billed using the 85X type of bill (TOB). Non-patient laboratory specimens are billed on TOB 14X.

MPFS rates contained in the HHH abstract file are used for payment of all physician/professional services rendered in a CAH that has elected the optional method. If a HCPCS code has a facility rate and a non-facility rate, the facility rate is paid. See Chapter 23 of Pub. 100-04, section 50.1 for the record layout for the HHH abstract file.

Sunday, October 23, 2016

Modifier 25 and E & M services

Multiple E&M services on the same day

• Reimbursement will be made for a preventive code with a problem focused code when modifier -25 is applied to the problem-focused code. Reimbursement for the preventive  service will be made at 100% of the contracted rate, and reimbursement for the problem focused service will be made at 50% of the contracted rate. This should only occur when a significant abnormality or pre-existing condition is addressed and additional work is required to perform the key components of a problem focused E&M service. Members have no copayment and/or deductible for routine physical exams. Members will be responsible for a copayment and/or deductible when a problem-focused code with modifier -25 is included on the claim. Therefore, the appropriate use of modifier -25 is critical since it will be transparent to members. Those services coded with modifier -25 will be regularly reviewed for coding accuracy.

• For all other services, FCHP allows one E&M code per day of service per physician group, per specialty regardless of the places of service.


E&M services submitted with Medicare annual wellness visit

Problem-focused E&M services will be allowed at 50% of the contracted rate when submitted with Medicare annual wellness visit codes G0438 or G0439 when modifier -25 is applied to the problem-focused code. This should only occur when a significant abnormality or pre-existing condition is addressed and additional work is required to perform the key components of a problem focused service. Members will be responsible for a copayment when a problem-focused code with modifier -25 is included on the claim. Therefore, the appropriate use of modifier -25 is critical since it will be transparent to members. Those services coded with modifier -25 will be regularly reviewed for coding accuracy.


E&M services provided with removal of impacted cerumen

FCHP does not reimburse removal of impacted cerumen (69210) when submitted when billed on the same date of service as E&M services.


E&M services provided with an office/outpatient procedure

• FCHP does not allow the separate reimbursement of E&M services when a substantial diagnostic or therapeutic procedure is performed. The “usual care” for the typical patient is already covered by the procedure.

• Append modifier -25 to the E&M service when a significant, separately identifiable E&M service is above and beyond the usual pre- and post-operative procedure rendered by the same physician on the same day as the procedure. Those services coded with modifier -25 will be reimbursed and will be regularly reviewed for coding accuracy.


E&M services provided with lab collection and screening services

• FCHP will not reimburse for G0102 (manual rectal neoplasm screening) when billed on the same date of service as a preventive medicine service (99381-87; 99391-97; S0610; S0612) regardless of location.

• FCHP will not reimburse for Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) when billed on the same date of service as a preventive medicine service (99381-87; 99391-97; S0610; S0612) regardless of location.

• FCHP will not reimburse for G0102 (manual rectal neoplasm screening) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.

• FCHP will reimburse only non-OBGYN PCPs for G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.

• FCHP will not reimburse for Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) when billed on the same date of service as an E&M service (99201-05; 99211-15) regardless of location.

• FCHP will not reimburse separately for 36415 (collection of venous blood by venipuncture) and/or 36416 (collection of capillary blood specimen i.e., finger, heel, ear stick) when billed along with an E&M office visit (99201-05; 99211-15) or preventative medicine service (99381-87; 99391-97) or office-based lab Proceure  codes (i.e. CLIA waived tests).

• FCHP will not reimburse separately for 99000; 99001 (lab specimen handling services) when billed with an E&M office visit (99201-05; 99211-15) or preventive medicine service (99381-87; 99391-97).

• FCHP does reimburse 36415 when it is the sole service provided.

• FCHP does reimburse 36416 when it is the sole service provided.

Thursday, October 6, 2016

Why Modifier is Important and where to report in the claim -


Modifiers provide a means to report or indicate a service or procedure that has been performed has been altered can be altered by a specific circumstance without changing the procedure code. Modifiers are used to increase accuracy in compensation, coding consistency, editing, and to capture payment data.

Tufts Health Plan accepts all standard CPT and HCPCS modifiers submitted in accordance with the appropriate CPT or HCPCS procedure code(s). Certain modifiers, when submitted appropriately, will impact compensation.

Note: The absence or presence of the appropriate modifier may result in a claim denial. 




BILLING INSTRUCTIONS

** Submit the appropriate modifier(s) with the corresponding CPT or HCPCS procedure codes on a CMS-1500 form for professional service in Box 24d Procedures, Services, or Supplies field

** Submit the modifier(s), when appropriate, in front of the corresponding CPT or HCPCS procedure codes on a UB-04 form for hospital services in Box 44 HCPCS/Rates field. Modifiers submitted after the procedure code may be incorrectly processed in the Tufts Health Plan system and delay payment or result in a denial.

Note: Annually and quarterly, HIPAA medical code sets3 undergo revision by CMS, AMA and CCI. Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-CM diagnosis codes. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes.



Additional Billing Information on Basic Modifiers

** Append modifier 26 to indicate the professional component that requires the use of a modifier whether in an office, inpatient or outpatient
setting.

** Append modifier TC to indicate the technical component that requires the use of a modifier, whether in an office, inpatient or outpatient setting.

** Submit global services on one line. Do not append a modifier when submitting claims for global services; providers should only bill globally when they have performed both the PC/TC components in an office setting.

** Append modifier 50 (bilateral procedure) to bilateral surgical procedure code(s) that require the use of a modifier.

** Submit bilateral surgical procedure code(s) on one claim line/service line with one unit.

** Append modifier 51 (multiple procedures) to surgical procedures that require the use of a modifier, that are billed in addition to the primary surgical procedure.



EDI Claim Submitter Information


** Submit claims in HIPAA compliant 837I format for institutional claims. Claims billed electronically with non-standard codes will reject.

** Claims submitted with non-standard modifiers will be rejected if submitted electronically.

Paper Claim Submitter Information

** Submit claims on an official claim form for professional services. Claim line(s) billed with non-standard codes will deny.

** All paper claims must be submitted on the official red claim forms. Black and white versions of these forms, including photocopied and faxed versions, will not be accepted and will be returned with a request to submit on the proper claim form.

** Submitted forms deemed incomplete will be rejected and returned to the submitter. The rejected claim and a letter stating the reason for rejection will be returned to the submitter, and a new claim with the required information must be resubmitted for processing.

Sunday, October 2, 2016

Usage of Modifier GA , GK, GL , GY AND GZ



GA  Waiver of Liability Statement Issued, as Required by Payer Policy

ABN required; beneficiary liable
To signify a line item is linked to the mandatory use of an ABN when charges both related to and not related to an ABN must be submitted on the same claim
Line item must be submitted as covered; Medicare makes a determination for payment


GK  Reasonable and Necessary Item/Service Associated with a –GA or –GZ modifier


ABN required if –GA is used; no liability assumption since this modifier should not be used on institutional claims
Not used on institutional claims. Use –GA or –GZ modifier as appropriate instead
Institutional claims submitted using this modifier are returned to the provider



GL Medically Unnecessary Upgrade Provided instead of Non-Upgraded Item, No Charge, No ABN

Can’t be used if ABN/HHABN is required, COPs may require notice, recommend documenting records; beneficiary liable
Use only with durable medical equipment (DME) items billed on home health claims (TOBs: 32x, 33x, 34x)
Lines submitted as non-covered and will be denied
GY  Modifier -  Item or Service Statutorily Excluded or Does Not Meet the Definition of Any Medicare Benefit

Non-covered by Medicare Statute (ex., service not part of recognized Medicare benefit)
Optional notice only, unless required by COPs; beneficiary liable
Use on all types of line items on provider claims. May be used in association with modifier –GX.
Lines submitted as non-covered and will be denied

GZ  Item or Service Expected to Be Denied as Not Reasonable and Necessary

May be non-covered by Medicare
Cannot be used when ABN or HHABN is actually given, recommend documenting records; provider liable
Available for optional use on demand bills NOT related to an ABN by providers who want to acknowledge they didn’t provided an ABN for a specific line
Lines submitted as non-covered and will be denied

Wednesday, September 28, 2016

Anesthesia Claims Modifiers


Physicians report the appropriate anesthesia modifier to denote whether the service was personally performed, medically directed, or medically supervised.

Specific anesthesia modifiers include:

AA - Anesthesia Services performed personally by the anesthesiologist;
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;
G8 - Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures;
G9 - Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition;
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals;
QS - Monitored anesthesia care service;
QX - CRNA service; with medical direction by a physician;
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist;
QZ - CRNA service: without medical direction by a physician; and
GC - these services have been performed by a resident under the direction of a teaching physician.

The GC modifier is reported by the teaching physician to indicate he/she rendered the service in compliance with the teaching physician requirements in §100.1.2. One of the payment modifiers must be used in conjunction with the GC modifier.

The QS modifier is for informational purposes. Providers must report actual anesthesia time on the claim.

The Part B Contractor must determine payment for anesthesia in accordance with these instructions. They must be able to determine the uniform base unit that is assigned to the anesthesia code and apply the appropriate reduction where the anesthesia procedure is medically directed. They must also be able to determine the number of anesthesia time units from actual anesthesia time reported on the claim. The Part B Contractor must multiply allowable units by the anesthesia-specific conversion factor used to determine fee schedule payment for the payment area.

Tuesday, September 20, 2016

Modifier G7, AA, AB and AD - Usage Guide

Providers Billing on the CMS 1500 Claim Form

Use the appropriate procedure/diagnosis code from the list above and the most appropriate modifier from the list below:

G7 - Termination of pregnancy resulting from rape, incest, or certified by physian as life-threatening.


Billing for Abortion Services


Abortions are not covered under the Medicare program except for instances where the pregnancy is a result of an act of rape or incest; or the woman suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused by the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.

Submit the HCPCS Modifier G7 with the following CPT codes when documentation supports the circumstances listed above:

59840 through 59841

59850 through 59852

59855 through 59857

59866


Providers Billing on the UB-04 Claim Form

Use the appropriate procedure/diagnosis code from those listed previously and the most appropriate condition code from the list below:

AA Abortion Due to Rape
AB Abortion Due to Incest
AD Abortion Due to Life Endangerment


In addition to the required coding, all claims must be submitted with the required documentation. Claims submitted for induced abortion-related services submitted
without the required documentation will be denied.

Induced Abortions to Save the Life of the Mother

Every reasonable effort to preserve the lives of the mother and unborn child must be made before performing an induced abortion. The services must be performed in a licensed health care facility by a licensed practitioner, unless, in the judgment of the attending practitioner, a transfer to a licensed health care facility endangers the life of the pregnant woman and there is no licensed health care facility within a 30 mile radius of the place where the medical services are performed.


“To save the life of the mother” means:

The presence of a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, as determined by the attending practitioner, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy is allowed to
continue to term.

The presence of a psychiatric condition which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term.

All claims for services related to induced abortions to save the life of the mother must be submitted with the following documentation:

** Name, address, and age of the pregnant woman
** Gestational age of the unborn child
** Description of the medical condition which necessitated the performance of the abortion
** Description of services performed
** Name of the facility in which services were performed
** Date services were rendered

And, at least one of the following forms with additional supporting documentation that confirms life-endangering circumstances:

** Hospital admission summary
** Hospital discharge summary
** Consultant findings and reports
** Laboratory results and findings
** Office visit notes
** Hospital progress notes

Friday, September 16, 2016

Usage of JW modifers

Change in policy regarding the use of the JW modifier for discarded Part B drugs and biologicals.

Effective January 1, 2017, providers are required to:

• Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals) and

• Document the discarded drug or biological in the patient's medical record when  submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded


The current policy allows MACs the discretion to determine whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specific details regarding how the discarded drug or biological information should be documented.

Be aware in order to more effectively identify and monitor billing and payment for discarded drugs and biologicals, CMS is revising this policy to require the uniform use of the JW modifier for all claims with discarded Part B drugs and biologicals

Thursday, September 8, 2016

Specific Modifiers for Distinct Procedural Services - Recap



New coding requirements related to Healthcare Common Procedure Coding System (HCPCS) modifier -59 could impact your reimbursement.

Change Request (CR) 8863 notifies MACs and providers that the Centers for Medicare and Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the - 59 modifier, a modifier used to define a "Distinct Procedural Service"

The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.

CR 8863 discusses changes to HCPCS modifier- 59, a modifier which is used to define a "Distinct Procedural Service." Modifier - 59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The 59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)." This modifier is associated abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.
The primary issue associated with the 59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
Different encounters;
Different anatomic sites; and
Distinct services.

The 59 modifier is
Infrequently (and usually correctly) used to identify a separate encounter;
Less commonly (and less correctly)used to define a separate anatomic site; and
More commonly (and frequently incorrectly) used to define a distinct service.

The 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place.CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.
CR 8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as - X{EPSU} modifiers) to define specific subsets of the 59 modifier:

XE Separate Encounter, A Service That Is Distinct Because IT Occurred During A Separate Encounter,
XS Separate Structure, A Service That Is Distinct Because It Was Performed on a Separate Organ/Structure,
XP Separate Practitioner, A Service That Is Distinct Because It was performed by a different practitioner, and
XU Unusual Non-Overlapping Service, The Use of a Service That Is Distinct Because It Does Not Overlap Usual Components Of the Main Service.

CMS will continue to recognize the 59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the 59 modifier in many instances, it may selectively require a more specific - X {EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the - XE separate encounter modifier but not the 59 or other - X {EPSU} modifiers. The - X {EPSU} modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.
The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a 59 modifier or a more selective - X {EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.
However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general 59 modifier, when necessitated by local program integrity and compliance needs.

Friday, August 26, 2016

Top 20 - Most commonly used Modifier

Modifier Description


22 Increased Procedural Service: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (eg, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care professional on the same Day of the Procedure or Other Service: It  may be necessary to indicate that on the day a procedure or service identified by a CPT® code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.

26 Professional Component: Certain procedures are a combination of a physician or other qualified health care professional component and a technical component . When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5 digit code.

51 Multiple Procedures: When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).

Note: This modifier should not be appended to designated “add-on” codes

52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. This provides a means of reporting reduced services without disturbing the identification of the basic service.

53 Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M care.

58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.



59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

73 Discontinued Outpatient Hospital / Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73.

74 Discontinued Outpatient Hospital / Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74.

78 Unplanned Return to the Operating / Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.

79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original
procedure. This circumstance may be reported by using modifier -79. (For repeat procedures on the same day, see modifier -76.)

CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission

FB Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device

FC Partial credit received for replaced device

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LT Left side (used to identify procedures performed on the left side of the body)

LM Left main coronary artery

RC Right coronary artery

RI Ramus intermedius coronary artery

RT Right side (used to identify procedures performed on the left side of the body)

TC Technical component

Wednesday, August 17, 2016

Definitions of the GA, GY, GX and GZ Modifiers


1. Definitions of the GA, GY, and GZ Modifiers

The modifiers are defined below:

GA - Waiver of liability statement on file.

GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.

GZ - Item or service expected to be denied as not reasonable and necessary.

2. Use of the GA, GY, and GZ Modifiers for Services Billed to Local Carriers

The GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit.

The GZ modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

The GA modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. (See http://www.cms.hhs.gov/medlearn/refabn.asp for additional information on use of the GA modifier and ABNs.)

The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe services, a “not otherwise classified code” (NOC) must be used with either the GY or GZ modifier.

3. Use of the GA, GY, and GZ Modifiers for Items and Supplies Billed to DMERCs

The GY modifier must be used when suppliers want to indicate that the item or supply is statutorily noncovered or is not a Medicare benefit.

The GZ modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

The GA modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe items or supplies, an NOC must be used with either the GY or GZ modifiers.

4. Use of the A9270

Effective January 1, 2002, the A9270, Noncovered item or service, under no circumstances will be accepted for services or items billed to local carriers. However, in cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the A9270 must continue to be used by suppliers to bill DMERCs for statutorily non-covered items and items that do not meet the definition of a Medicare benefit.

5. Claims Processing Instructions

At carrier and DMERC discretion, claims submitted using the GY modifier may be auto-denied. If the GZ and GA modifiers are submitted for the same item or service, treat the item or service as having an invalid modifier and therefore unprocessable.

F. GZ Modifier

Effective for dates of service on and after July 1, 2011, contractors shall automatically deny claim line(s) items submitted with a GZ modifier. Contractors shall not perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make all language published in educational outreach materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. When claim line(s) items submitted with the Modifier GZ are denied, contractors shall use the following codes: Group Code CO (Provider/Supplier liable) and CARC 50 defined “These services are non-covered services because this is not deemed a ‘medical necessity’ by the payer.



The modifiers are defined below:

GA - Waiver of liability statement on file.

 GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.

GZ - Item or service expected to be denied as not reasonable and necessary.


GZ Modifier

Effective for dates of service on and after July 1, 2011, A/B MACs (B) shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs (B) shall not perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make all language published in educational outreach materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. When claim line(s) items submitted with the Modifier GZ are denied, A/B MACs (B) shall use the following codes: Group Code CO (Provider/Supplier liable) and CARC 50 defined “These services are non-covered services because this is not deemed a ‘medical necessity’ by the payer.


2. Use of the GA, GY, and GZ Modifiers for Services Billed to A/B MACs (B)

The GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit.

The GZ modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

The GA modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. (See https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf for additional information on use of the GA modifier and ABNs.)

The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe services, a “not otherwise classified code” (NOC) must be used with either the GY or GZ modifier.


GA and GZ Modifiers

Providers and suppliers use GA and GZ modifiers to bill for certain services or items that they expect to be denied as not reasonable and necessary.3 They may use these modifiers when they are uncertain about whether a claim should be paid. For example, a provider may not know whether a beneficiary already had a particular laboratory test that Medicare covers only once a year 4 or a supplier may suspect that the beneficiary already has the item it is providing.5  Providers and suppliers may also use these modifiers when they are certain that the claim should not be paid. For example, a provider may know that Medicare does not pay for a particular test for a beneficiary with a given condition, but because the beneficiary requests it, the provider submits the claim to Medicare for a decision.6  The beneficiary may need Medicare to deny the claim so that it can be submitted to the beneficiary’s secondary insurance.



GZ Modifiers: Beginning in January 2002, Medicare required providers and suppliers to use the GZ modifier for claims they expect to be denied as not reasonable and necessary for which they do not have an ABN on file.8  In these cases, if Medicare denies the claim as not reasonable and necessary, the beneficiary cannot be held liable for the cost of the service or item. Table 1 provides the definitions of GA and GZ modifiers for Part B claims.

Definitions of GA and GZ Modifiers for Part B Claims

Modifier         Definition

GA Service or item is not considered reasonable and necessary; ABN is on file

GZ Service or item is not considered reasonable and necessary; ABN is not on file


Medicare Part B Claims Processing

CMS contracts with Medicare Administrative Contractors (MAC) to process and pay Part B claims.12 These contractors also apply claims processing “edits”—i.e., system checks—to prevent improper payments; conduct medical reviews and data analyses of claims; and conduct outreach and education to providers. Edits flag a claim for automatic denial or for contractor review to ensure that the claim is appropriate.

CMS provides contractors with various instructions about how to process claims with G modifiers. CMS required contractors to automatically deny claims with GZ modifiers for services or items that were provided on or after July 1, 2011. 13 Currently, CMS does not have any specific instructions for claims with GA modifiers, except for those submitted with both a GA and GZ modifier; CMS instructs contractors to treat such  claims as unprocessable.14 For claims with GY modifiers, CMS allows contractors to deny these claims at their discretion. Finally, CMS has not issued instructions for processing Part B claims with GX modifiers.

Processing Instructions for Part B Claims With G Modifiers

Modifier             Processing Instructions

GA   Claims with both a GA and a GZ modifier for the same service or item should be treated as unprocessable.


GZ Effective July 1, 2011, GZ claims must be automatically denied.

GY     Effective January 2002, claims with GY modifiers may be automatically denied at the discretion of the MACs.

GX No instructions

3. Use of the GA, GY, and GZ Modifiers for Items and Supplies Billed to DME MACs

The GY modifier must be used when suppliers want to indicate that the item or supply is statutorily non-covered or is not a Medicare benefit.

The GZ modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

The GA modifier must be used when suppliers want to indicate that they expect that Medicare will deny an item or supply as not reasonable and necessary and they do have on file an ABN signed by the beneficiary.

The GY and GZ modifiers should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe items or supplies, an NOC must be used with either the GY or GZ modifiers.


A GY modifier is used by providers when billing to indicate that an item or service is statutorily excluded and is not covered by Medicare. Examples of statutorily excluded services include hearing aids and home infusion therapy.

When these types of claims are rejected, we also will remind the provider to allow 30 days for the crossover process to occur or instruct the provider to submit the claim with only GY modifier service lines indicating the claim only contains statutorily excluded services.

Medicare statutorily excluded services – just file once to your local Blue Cross Blue Shield plan

There are certain types of services that Medicare never or seldom covers, but a secondary payer such as Anthem may cover all or a portion of those services. These are statutorily excluded services. For services that Medicare does not allow, such as home infusion, providers need only file statutorily excluded services directly to their local plan using the GY modifier and will no longer have to submit to Medicare for consideration. These services must be billed with only statutorily excluded services on the claim and will not be accepted with some lines containing the GY modifier and some lines without.

For claims submitted directly to Medicare with a crossover arrangement where Medicare makes no allowance, providers can expect the member’s benefit plan to reject the claim advising the provider to submit to their local plan when the services rendered are considered eligible for benefit. These claims should be resubmitted as a fresh claim to a provider’s local plan with the Explanation of Medicare Benefits (EOMB) to take advantage of provider contracts. Since the services are not statutorily excluded as defined by CMS, no GY modifier is required. However, the submission of the Medicare EOMB is required. . This will help ensure the claims process consistent with the providers contractual agreement..

Providers who render statutorily excluded services should indicate these services by using GY modifier at the service line level of the claim. Providers will be required to submit only statutorily excluded service lines on a claim (cannot combine with other services like Medicare exhaust services or other Medicare covered services)

? The provider’s local plan will not require Medicare EOMB for statutorily excluded services submitted with a GY Modifier.

If providers submit combined line claims (some lines with GY, some without) to their local plan, the provider’s local plan will deny the claims, instructing provider to split the claim and resubmit

Original Medicare -- The GY modifier should be used when service is being rendered to a Medicare primary member for statutorily excluded service and the member has Blue secondary coverage, such as an Anthem Medicare Supplement plan. The value in the SBR01 field should not be “P” to denote primary.

Medicare Advantage -- Please ensure SBR01 denotes “P” for primary payer within the 837 electronic claim file. This helps ensure accurate processing on claims submitted with a GY modifier.

The GY modifier should not

• Commercial claims be used when submitting:

• Federal Employee Program claims

• In-patient institutional claims. Please use the appropriate condition code to denote statutorily excluded services.



Medicare usage guidelines


You should be aware of some details in the use of these modifiers.

• -GA Modifier:

• Medicare systems will automatically deny lines submitted with the -GA modifier and covered charges on institutional claims;

• Medicare systems will assign beneficiary liability to claims automatically denied when the –GA modifier is present; and

• Medicare will use claim adjustment reason code 50 (These are noncovered services because this is not deemed a ‘medical necessity’ by the payer.) when denying lines due to the presence of the –GA modifier.

• -GX Modifier

• Medicare systems will recognize and allow the –GX modifier on claims, but will return your claim if the –GX modifier is used on any line reporting covered charges;

• Medicare systems will allow the –GX modifier to be reported on the same line as the following modifiers that indicator beneficiary liability: -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit), -TS (Follow-up service);

• Medicare systems will return your claim if the –GX modifier is reported on the same line as any of the following liability-related modifiers: -EY (no doctor's order on file), -GA, -GL (medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN), -GZ (item or service expected to be denied as not reasonable and necessary), -KB (Beneficiary requested upgrade for ABN, more than four modifiers identified on claim), -QL (Patient pronounced dead after ambulance is called), -TQ (basic life support transport by a volunteer ambulance provider);

• Medicare systems will automatically deny lines (using claim adjustment reason code 50) submitted with the -GX modifier and non-covered charges, and will assign beneficiary liability to claims automatically denied when the –GX modifier is present.

Final Note: Other than the policy and processing changes described in CR 6563, all other policies and processes regarding non-covered charges and liability continue as stated in the Medicare Claims Processing Manual, Chapter 1 (General Billing Requirements), Section 60 (Provider Billing of Noncovered Charges) and in the requirements defined in previous change requests. 


GA Modifier

* The GA code signifies the “Waiver of Liability Statement Issued as Required by Payer Policy.”
* The GA modifier does not signify that the care is maintenance.
* If you place the GA modifier on a code you must have a signed ABN form in the file.
* It is appropriate to report the GA modifier when the beneficiary refuses to sign the ABN.
* For chiropractors, the –AT modifier (which signifies that the patient is under active treatment and that improvement is expected) is only used with the procedure codes 98940, 98941 and 98942.
* With the new changes in effect, the –GA modifier can only be used with procedure codes 98940, 98941 and 98942

GY Modifier

* The GY modifier is used to indicate that a service is not covered by Medicare
* Use the GY modifier when a patient’s secondary insurance needs a rejection by Medicare before they will pay for a service

GZ Modifier

* The GZ modifier is used when you expect Medicare to deny the service and you do not have an ABN form signed.
* Use this modifier when you forgot the ABN.
* Expect an audit if you use this modifier Q6 Modifier
* Services provided by a Locum Tenens physician
* Use this modifier when you have another doctor filling in for you.
* A Locum Tenens doctor can fill in for 60 days.

GY and GX Modifiers

Beginning in January 2002, Medicare allowed providers and suppliers to use the GY modifier to indicate that a service or item is not covered by Medicare, either because it is statutorily excluded (e.g., hearing aids) or does not meet the definition of any Medicare benefit (e.g., surgical dressings that are used to clean or protect intact skin).9

Because Medicare does not cover these services or items, the beneficiary is liable for payment. No ABN is required with the GY modifier. The provider or supplier may use this modifier when a beneficiary needs Medicare to deny the claim so that it can be submitted to the beneficiary’s secondary insurance.

In April 2010, Medicare established the GX modifier. It indicates that a service or item is statutorily excluded and that the provider or supplier voluntarily gave the beneficiary an  ABN.10 In 2010, Medicare provided instructions to contractors to automatically deny Part A claims with the GX modifier for noncovered charges.

11 Medicare has not issued similar instructions for Part B claims. Table 2 provides the definitions of GY and

GX modifiers. Table 2: Definitions of GY and GX Modifiers for Part B Claims Modifier Definition

GY Service or item is statutorily excluded or does not meet the definition of any Medicare benefit; ABN is not required.

GX Service or item is statutorily excluded and the provider or supplier voluntarily notified the beneficiary with an ABN.

Medicare Part B Claims Processing

CMS contracts with Medicare Administrative Contractors (MAC) to process and pay Part B claims.12 These contractors also apply claims processing “edits”—i.e., system checks—to prevent improper payments; conduct medical reviews and data analyses of claims; and conduct outreach and education to providers. Edits flag a claim for automatic denial or for contractor review to ensure that the claim is appropriate.

CMS provides contractors with various instructions about how to process claims with G modifiers. CMS required contractors to automatically deny claims with GZ modifiers for services or items that were provided on or after July 1, 2011. 13 Currently, CMS does not have any specific instructions for claims with GA modifiers, except for those submitted with both a GA and GZ modifier; CMS instructs contractors to treat such claims as unprocessable.14 For claims with GY modifiers, CMS allows contractors to deny these claims at their discretion. Finally, CMS has not issued instructions for processing Part B claims with GX modifiers.

Most read cpt modifiers