Physician Practice

The next transition for rural health clinics: modifier -CG

Physician Practice Insider, October 18, 2016

Every October 1, providers are able to count on some changes to reimbursement principles taking effect, specifically the implementation of new, revised, and deleted ICD-10 diagnosis and procedure codes, as well as any changes that impact the Inpatient Prospective Payment System, just to name a few.

But while changes are certain, this year they may only add to existing confusion for rural health clinics (RHC). It has already been a long 6-months’ worth of changes for this specialty provider, and, as far as Medicare billing transitions have gone, one that has been particularly difficult. CMS has issued several temporary work-arounds for dates of service within the period April 1–September 30 to get RHCs through the period until the October 1 claims filing date arrives, which would allow clinics to then bill for its services as the original regulation had intended.

Since April 1, 2016, RHCs have been required to report all HCPCS codes under the appropriate revenue code and charges ≥ $.01. To receive an all-inclusive rate (AIR) payment, a visit from the CMS Qualifying Visit List had to be reported. If the visit was solely for any HCPCS listed in this document in red italics, the RHC was required to hold the entire claim until October 1. If the claim included any other separately payable HCPCS code with one of the red codes, the claim could have been submitted for payment.

Now that October 1 has arrived, RHCs may release any claims that have been held since April 1. However, they must append modifier -CG to the visit code reported with revenue code 052X and/or 0900 to trigger the AIR payment. This line also includes the total charges that will be used to calculate the patient’s financial responsibility. Since these claims have been held for six months, RHCs will want to move these to the front of their billing que to prevent any timely filing issues.

When a preventive health service is the purpose for the visit, RHCs should report modifier -CG on the revenue code 052x service line with the preventive HCPCS code. Medicare will pay 100% of the AIR for the preventive health service and in certain circumstances, the patient’s deductible and coinsurance will be waived.

October 1 also ushered in the ability for RHCs to use either modifier -25 or -59 on the additional visit line reported with revenue code 052X when appropriately claiming that two medical visits occurred on the same date of service. (RHCs must report modifier -CG on both lines to request two AIR payments.) CMS has not provided any guidance as to which modifier should be reported first; however, using common claims processing logic, modifier -25 would be reported first to bypass any duplicate service edits, and modifier -CG would be reported next to request payment.

This article originally appeared on Medicare Compliance Watch.

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