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Know Before You Bill – Medicare Modifiers

Know Before You Bill-Medicare Modifiers

How disappointing it is when a clinic completes the intake process, exam, treatment and detailed documentation on a patient only to receive a claim denial for ‘missing modifier or incorrect modifier’. Are misapplied modifiers killing your Medicare reimbursement? Take a moment to check out these helpful tips!

Below is a list of modifiers, their descriptions and/or instructions, and what, if any affect the modifier has on the Medicare payment. The list is divided into two categories: modifiers used only on chiropractic manipulative treatment (CMT) codes and modifiers used on all other services.

Modifiers Used with Spinal CMT Codes (98940, 98941, and 98942 only)

Code Description/Instruction Effect on Medicare Payment
AT
  • When you expect Medicare to pay for active treatment and are reporting CPT codes
    • 98940
    • 98941
    • 98942
  • If the claim is denied, correct it or appeal it
  • Typically, an ABN is not signed when billing with an AT modifier
Medicare will consider the service for payment since it has been deemed “active treatment” They will apply appropriate screens and consider whether the service is medically necessary.
GA

Waiver of liability statement on file

GA stands for “Got ABN!”

  • Indicates patient has been given advance notice that a service normally covered may not be covered today because the CMT service is deemed maintenance care.
  • The signed ABN is retained in the patient’s medical record
If the patient chooses Option 1 on the ABN form, you must bill the service. The GA modifier is appended to the appropriate CMT code.
GZ
  • Indicates that you expect an otherwise-covered service (98940-98942) to be denied as not reasonable and necessary and you failed to get an ABN signed prior to rendering the service.
  • GZ = “Geez, I forgot the ABN and I better not do that again.”
Effective July 1, 2011, all claim line items submitted with GZ modifiers will be denied automatically They will not be subject to complex medical review.

 

Modifiers Used with Non-Spinal CMT Codes (Every other service ordered or delivered by a DC)

Code Description/Instruction Effect on Medicare Payment
GY
  • Indicates when an item or service is statutorily excluded or never covered when ordered or delivered by a chiropractor.
  • This refers to every service other than the three spinal CMT codes (98940-98942)
  • GY = “Gee, WHY doesn’t Medicare cover this?”
  • You do not have to bill these services to Medicare unless the patient instructs you to do so
  • You do bill the patient and collect for these services from the patient
  • Billing must include this modifier to generate an appropriate denial from Medicare so a secondary payer will consider the service, if necessary
GP
  • Use this modifier with services delivered under an outpatient physical therapy (PT) plan of care
  • GP = “Got PT.”
  • For certain non-covered PT services, you may have to include this modifier with your GY modifier
  • Check with your individual Medicare Administrative Contractor (MAC) for their rules on the use of this modifier
GX

Notice of Liability Issued, Voluntary Under Payer Policy.

  • Used to report when a voluntary ABN is issued for services never covered when ordered or delivered by a chiropractor
  • Only use if you chose to notify a Medicare patient of statutorily excluded services using the official Medicare ABN form. (Not recommended)
  • Included with the GY or GP modifiers, if necessary.
  • Medicare automatically rejects claims that have a GX modifier applied to covered charges.

Heads Up!

CPT Code 97010: Medicare considers this code (hot/cold packs) a ‘bundled’ service. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. In this instance, it means services described by 97010 are not separately billable when rendered to a Medicare patient.

CPT Code 97014: When you submit electrical muscle stimulation to Medicare for the purposes of denial and to be eligible for submission to a secondary plan, you must use G0283 to receive the proper denial from Medicare. You then will use the modifier GY and possibly GP (if your Medicare carrier requires this) to receive a denial that will allow you to submit to a secondary carrier. This code may or may not be accepted by other carriers and you may have to modify your practice systems to use G0283 only for submission of electrical muscle stimulation treatment to Medicare and the CPT code 97014 to other carriers.

Now that you are on your way to appending proper modifiers, there is one more billing topic we need to address. It is related to patient billing for those who are Medicare QMBs.

 

 

 

 

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After watching the webinar “Security Risk Management, A HIPAA Requirement”, I went to the government website and spent 4 hours trying to research what I needed to do and had to walk away as I was overwhelmed.  After contacting my Account Manager, and setting a time to review the Compliance materials that are available at KMC University, I now feel this is what I was looking for…simple steps to walk from A-Z.

Amy D.