Principal Physician of Record
Instructions
This modifier distinguishes the Principal Physician who oversees patient's care when performing evaluation and management (E/M) services and is only appended to an appropriate E/M code by that physician. It is imperative, so that other specialties may bill their claims for the same E/M code and not receive denials.
Correct Use
Append to initial/subsequent E/M codes only
99221 – 99223 (Hospital-Initial)
99231 – 99233 (Hospital-Subsequent)
99291 (Critical Care)
99304 – 99306 (SNF-Initial)
99307 – 99310 (SNF-Subsequent)
Only principal physician of record appends to E/M code
Incorrect Use
Inappropriate for another physician to append (primary or specialty)
Claim Coding Example
Treatment Description
CPT/Modifier
Dr. Medi's Bill
Principal physician of record initial inpatient visit
99222 AI
Dr. Care's Bill
Another specialty; initial inpatient visit, same day
99222
Modifier AY
Item or service furnished to ESRD patient - not for ESRD treatment
Instructions
If an End Stage Renal Disease (ESRD) facility needs to report a lab service (not related to ESRD treatment), they must include modifier AY to indicate item/service was not for treatment of ESRD.
Treatment
CPT/Modifier
Assay of Creatinine
82565 AY
Correct Use
ESRD facilities reporting Daptomycin revision Separate payment available for J0878 Injection (Daptomycin, 1 mg) when furnished to an ESRD patient (not for ESRD treatment)
Incorrect Use
Inappropriate to bill J0890 with modifier AY Consolidated billing requirement –not overridden with AY modifier
Modifiers CD, CE and CF (also known as 50/50 rule modifiers) no longer valid for use on independent laboratory claims
Correct Claim Coding
Treatment
CPT/Modifier
Assay of Creatinine
82565 AY
Modifier CR
Catastrophe/Disaster
Correct Use
This modifier must be submitted only when an item or service is impacted by an emergency or disaster.
Use for both institutional and non-institutional billing
Effective August 31, 2009: use of CR modifier is mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on the presence of a "formal waiver"
Formal Waiver: waiver of a program requirement that otherwise would apply by statute or regulation
Two types of formal waivers
Waiver of a requirement specified in Section 1135(b) of the Social Security Act. This may permit Medicare payment in a circumstance where payment would otherwise be barred.
Waiver based on a provision of the Title XVIII of the Act or its implementing regulations.
In the event of a disaster or emergency, CMS will issue specific guidance to Medicare contractors.
Incorrect Use
When there are no instructions from CMS to use the modifier
Item/service/claim was not affected by an emergency/disaster
Modifier GC
Service has been performed in part by a resident under the direction of a teaching physician
Correct Use
Append to service that has been completed by a resident in a teaching facility in part under direction and supervision of a teaching physician.
Medicare does not pay for any service furnished by a medical student as defined in Internet Only Manual (IOM), Claims Processing Manual 100-04, Chapter 12, Section 100 This link takes you to an external website..
Append in second modifier field when supervising/teaching anesthesiologist is involved in two concurrent anesthesia cases with one resident (or "fellow"), he/she may bill usual base units and anesthesia time for amount of time present with resident throughout pre, intra and post anesthesia care.
Incorrect Use
Append to service when teaching physician is not involved with any part of care
Teaching Physician Documentation
Teaching physicians shall personally document that they performed the service or were physically present during key or critical portions of the service and their participation in the management of the patient.
The physician is able to refer to the resident's documentation; however, a statement by the attending (teaching) physician is required and must include essential and independent documentation to tie into the resident's documentation. Without such documentation, no reimbursement can be made.
Examples:
Acceptable Patient became hypoxic and hypotensive. I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs and oxygen. I reviewed the resident's assessment and plan of care.
Unacceptable
I saw the patient and agree with the resident.
NOTE: In a time based setting, such as critical care, time spent teaching does not count towards the critical care time of the physician; nor does the time the resident spent with the patient. Only time spent together with the patient or the teaching physician alone can be counted towards critical care time.
Modifier GJ
"Opt out" physician or practitioner emergency or urgent services
Instructions
In an emergency or urgent care situation, a physician/practitioner who opts out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the provider may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary's behalf.
Correct Use
Example - Physician was called in to see a patient in the emergency room whom he has not seen before and no contract was signed
Claim Coding Example
CPT Code 99282, Modifier GJ
Incorrect Use
Opt out physician to append for non-emergent services that have a private contract with patients.
Resource
Modifier GV
The attending physician is not employed or paid under agreement by the patient's Hospice provider.
Instructions
This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:
Service was rendered to a patient enrolled in a Hospice.
Service was provided by a physician or non-physician practitioner identified as the patient's 'attending physician' at the time of that patient's enrollment in the Hospice program
Submit this modifier regardless of whether the services were related to the patient's terminal condition
Service was provided by a physician employed by the Hospice, you may not submit this modifier
Service was provided by a physician not employed by the Hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier
Example: An independent attending physician or independent laboratory interprets the surgical pathology (88305) from a patient with a terminal illness related service. The professional component is billed to the Medicare contractor. If there is no professional component (e.g., clinical lab tests), then the Part A Hospice should only be billed.
Date of Service
Treatment
CPT/Modifier
Surgical pathology (professional component)
Bill to Part B: 88305 26GV 01/14/12
Surgical pathology (technical component)
Bill to Hospice: 88305 TC
Same rules apply for diagnostic tests
Date of Service - Treatment - CPT/Modifier
09/25/12 - Chest x-ray (professional component)
Bill to Part B: 71010 26GV
09/25/12 - Chest x-ray (technical component)
Bill to Hospice: 71010 TC
Modifier GW
Condition not related to the patient's terminal condition
Instructions
Submit this modifier when a service is rendered to a patient rolled in a hospice, and the service is unrelated to the patient's terminal condition.
All providers must submit this modifier when this condition applies.
Claim Coding Example
Patient is on hospice for congestive heart failure and goes to the office for a toe nail trim. The procedure is unrelated. The GW modifier should be added to the CPT for the toe nail trim.
Modifier Q1
Routine clinical service provided in a clinical research study that is in an approved clinical research study
Correct Use
When a routine clinical service is performed as part of an approved clinical research study
Routine clinical services are defined as those items and services that are covered for Medicare beneficiaries outside of the clinical research study
Used for direct patient management within the study
Does not meet definition of investigational clinical services
Routine clinical services may include items or services required solely for the provision of the investigational clinical services (e.g., administration of a chemotherapeutic agent), clinically appropriate monitoring, whether or not required by investigational clinical service (e.g., blood tests to measure tumor markers) and items or services required for prevention, diagnosis, or treatment of research related adverse events (e.g., blood levels of various parameters to measure kidney function)
Incorrect Use
When service is not part of an approved clinical research study
Modifier Q0
Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Correct Use
When an investigational service is performed as part of an approved clinical research study
Investigational clinical services are defined as those items and services that are being investigated as an objective within study
Investigational clinical services may include items or services that are approved, unapproved or otherwise covered (or not covered) under Medicare
Incorrect Use
When service is not part of an approved clinical research study
When service is not investigative in nature
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