Saturday, August 22, 2020

CPT code 93000, 93040, 93041, 93042, 93010 - ECG and EKG codes

 CPT® Code Procedure Description  

93000 Electrocardiogram Routine ECG with at least 12 leads; with interpretation and report  

93005 Electrocardiogram Routine ECG with at least 12 leads; tracing only, without interpretation and report  

93010 Electrocardiogram Routine ECG with at least 12 leads; interpretation and report only  

93040 Rhythm ECG One to three leads; with interpretation and report  

93041 Rhythm ECG One to three leads; tracing only, without interpretation and report  

93042 Rhythm ECG One to three leads; interpretation and report only

CPT Manual Instructions for Reporting Electrocardiographic Recording

• Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.

• There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report.

• It is not appropriate to use these codes for reviewing telemetry monitor strips taken  from a monitoring system.

• The need for an electrocardiogram or rhythm strip should be supported by  documentation in the patient medical record.

Bundled Services per CPT Manual

• Do not report 93040-93042 when performing 93279-93289, 93291-93296, or  93298-93299

Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use of an ECG. ICD-10-CM codes and/or ranges are provided below to help with your decision process.


Codes 70010-79999, 93000-93010, and 0178T-0180T are used for reporting radiology procedures.


-26 Professional Component

-76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care  Professional

-77 Repeat Procedure by Another Physician or Other Qualified Health Care  Professional

-ET Emergency services

Policy Statement

Medical Imaging and Electrocardiogram (ECG/EKG) Interpretation

Payment will be made for only one interpretation of any given x-ray, CT, MRI, ultrasound or ECG/EKG. Subsequent interpretations or readings by another physician (indicated by the -77 modifier) will not be covered. A re-interpretation by another physician is considered an integral part of the primary physician's medical care.

However, if the patient's condition warrants an immediate interpretation of an imaging study (emergency treatment -ET modifier), payment may be made to the attending or admitting physician even when a hospital staff physician also performs an imaging study interpretation.


• Include documentation in the patient’s records to indicate medical necessity for a separate service.

• Confirm that proper ICD-10-CM diagnosis codes are reported to justify medical necessity of ECG monitoring.

• When appropriate, a modifier may be reported and support documentation should be provided with the claim.

• Some payers may have specific requirements for using certain codes, including prior authorization, restricted medical diagnoses or specialty provider types.


Indications and Limitations of Coverage

Nationally Covered Indications

The following indications are covered nationally unless otherwise indicated:

** Computer analysis of EKGs when furnished in a setting and under the circumstances required for coverage of other EKG services.

** EKG services rendered by an independent diagnostic testing facility (IDTF), including physician review and interpretation. Separate physician services are not covered unless he/she is the patient's attending or consulting physician.

** Emergency EKGs (i.e., when the patient is or may be experiencing a life threatening event) performed as a laboratory or diagnostic service by a portable x-ray supplier only when a physician is in attendance at the time the service is performed or immediately thereafter.

** Home EKG services with documentation of medical necessity.

** Transtelephonic EKG transmissions (effective March 1, 1980) as a diagnostic service for the indications described

below, when performed with equipment meeting the standards described below, subject to the limitations and conditions specified below. Coverage is further limited to the amounts payable with respect to the physician's service in interpreting the results of such transmissions, including charges for rental of the equipment. The device used by the beneficiary is part of a total diagnostic system and is not considered DME separately. Covered uses are to:

o Detect, characterize, and document symptomatic transient arrhythmias;

o Initiate, revise, or discontinue arrhythmic drug therapy; or,

o Carry out early post-hospital monitoring of patients discharged after myocardial infarction (MI); (only if 24- hour coverage is provided, see below).

Certain uses other than those specified above may be covered if, in the judgment of UnitedHealthcare, such use is medically necessary.

Additionally, the transmitting devices must meet at least the following criteria:

** They must be capable of transmitting EKG Leads, I, II, or III; and,

** The tracing must be sufficiently comparable to a conventional EKG.

24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI is only covered if provision is made for such 24-hour attended coverage in the manner described here: 24-hour attended coverage means there must be, at a monitoring site or central data center, an EKG technician or other non-physician, receiving calls and/or EKG data; tape recording devices do not meet this requirement. Further, such technicians should have immediate, 24-hour access to a physician to review transmitted data and make clinical decisions regarding the patient. The technician should also be instructed as to when and how to contact available facilities to assist the patient in case of emergencies.

ICD-10-CM Description

ICD-10-CM Code/ Range

Abnormalities of heart beat R00.0-R00.9

Angina pectoris 120.0-120.9

Atherosclerotic heart disease I25.10-I25.119

Atrioventricular and left bundle-branch block 144.0-144.7

Cardiac arrest I46.2-I46.9

Cardiac murmurs and other cardiac sounds R01.0-R01.2

Cardiomyopathy I42.0-I42.9

Cardiomyopathy in diseases classified elsewhere I43

Essential (primary) hypertension I10

Gangrene, not elsewhere classified I96

Hypertensive heart disease I11.0-I11.9

Multiple valve diseases I08.0-I08.9

Old myocardial infarction I25.2

Other acute ischemic heart diseases I24.0-I24.9

Other cardiac arrhythmias I49.0-I49.9

Other conduction disorders I45.0-145.9

Other pulmonary heart diseases I27.0-I27.9

Pain in chest R07.1-R07.9

Rheumatic aortic valve diseases I06.0-I06.9

Rheumatic mitral valve diseases I05.0-I05.9

ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I21.0-I21.4

Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I22.0-I22.9

Friday, July 24, 2020

CPT G0108, G0109 and MODIFIER GQ

HCPCS Code Description

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

Modifier Description

GQ Via asynchronous telecommunications system

Place of Service Description

02 Telehealth: The location where health services and health related services are provided or received, through a telecommunication system.


The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services.

Certified Providers

A designated certified provider bills for DSMT provided by an accredited DSMT program. C ertified providers must submit a copy of their accreditation certificate to the contractor. The statute states that a “certified provider” is a physician or other individual or entity designated by the Secretary that, in addition to providing outpatient selfmanagement training services, provides other items  and services for which payment may be made under title XVIII,

and meets certain quality standards. The CMS is designating all providers and suppliers that bill Medicare for other individual services such as hospital outpatient departments, renal dialysis facilities, physicians and durable medical equipment suppliers as certified. All suppliers/providers who may bill for other Medicare services or items and who represent a DSMT program that is accredited as meeting quality standards can bill and receive payment for the entire DSMT program. Registered dietitians are eligible to bill on behalf of an entire DSMT program, as long as the provider has obtained a Medicare provider number. A dietitian may not be the sole provider of the DSMT service. There is an exception for rural areas. In a rural area, an individual who is qualified as a registered dietitian and as a certified diabetic educator who is currently certified by an organization approved by CMS may furnish training and is deemed to meet the multidisciplinary team requirement. C ertified providers may be asked to submit updated accreditation documents at any time or to submit outcome data to an organization designated by CMS.

Frequency of Training

The initial year for DSMT is the 12 month period following the initial date. Medicare will cover initial training that meets the following conditions:
• Is furnished to a beneficiary who has not previously received initial or follow-up training under HCPCS codes G0108 or G0109;
• Is furnished within a continuous 12-month period;
• Does not exceed a total of 10 hours (the 10 hours of training can be done in any combination of 1/2 hour increments);
• With the exception of 1 hour of individual training, training is usually furnished in a group setting, which can contain other patients besides Medicare beneficiaries, and;
• One hour of individual training may be used for any part of the training including insulin training.

Follow-Up Training

Medicare covers follow-up training under the following conditions:
• No more than 2 hours individual or group training per beneficiary per year;
• Group training consists of 2 to 20 individuals who need not all be Medicare beneficiaries;
• Follow-up training for subsequent years is based on a 12 month calendar after completion of the full 10 hours of initial training;
• Follow-up training is furnished in increments of no less than one-half hour; and
• The physician (or qualified non-physician practitioner) treating the beneficiary must document in the beneficiary's medical record that the beneficiary is a diabetic.

Coverage Requirements for Individual Training

Medicare covers training on an individual basis for a Medicare beneficiary under any of the following conditions:

• No group session is available within 2 months of the date the training is ordered;
• The beneficiary’s physician (or qualified non-physician practitioner) documents in the beneficiary’s medical record that the beneficiary has special needs resulting from conditions, such as severe vision, hearing or language limitations or other such special conditions as identified by the treating physician or non-physician practitioner, that will hinder effective participation in a group training session; or
• The physician orders additional insulin training.
• The need for individual training must be identified by the physician or non-physician practitioner in the referral.


Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit’s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable. The in-person injection training, when provided, may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the –GT or –GQ modifier with HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.

As specified in the Medicare Benefit Policy Manual, chapter 15, section 300.2, individual DSMT services may be furnished by a physician, individual, and group DMST services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by, a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 C FR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a licensed PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.

For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit.

DMEPOS Suppliers

The DMEPOS suppliers are reimbursed for diabetes training through local carriers. In order to file claims for DSMT, a DMEPOS supplier must be enrolled in the Medicare program with the National Supplier Clearinghouse (NSC ). The supplier must also meet the quality standards of a CMS-approved national accreditation organization as stated above. DMEPOS suppliers must obtain a provider number from the local carrier in order to bill for DSMT.

The carrier requires the appropriate completed form, along with an accreditation certificate as part of the provider application process. After it has been determined that the quality standards are met, a billing number is assigned to the supplier. Once a supplier has received a National Provider Identification (NPI) number, the supplier can begin receiving reimbursement for this service.

Diabetes Education

Yes. In order for a client to participate in the diabetes education program, a licensed primary health care provider must refer the client to a program for diabetes education. Hospitals must be approved by the Washington State Department of Health (DOH) as a diabetes education provider.

For diabetes education services provided in a hospital outpatient setting, the provider must:
• Bill using revenue code 0942.
• Provide a minimum of 30 minutes of education/management per session.

Note: Services provided in an outpatient hospital department or hospital-based clinic must be billed on a UB-04 claim form. Services provided in a non-hospital based clinic or a physician’s office must be billed on a CMS-1500 claim form.

Note: The agency requires authorized hospital outpatient diabetes education programs to bill with revenue code 0942. Claims submitted using HCPCS codes G0108 and G0109 will be denied.

Denial reasons

Providers should be aware that MACs will return claims if you append demo code 85, and:

• You are not on the CEC participant provider list with a telehealth record type; or
• DOS “from date” is prior to your telehealth effective date, or
• DOS “from date” is after your telehealth termination date, or
• The DOS “from date” is prior to the beneficiary’s effective date; or
• The DOS “from date” is after the beneficiary’s termination date, or
• The DOS “from date” is more than 90 days after the beneficiary’s termination date; or
• The beneficiary was not aligned to the same ESCO with which you are participating, as identifi ed by ESCO ID; or
• The claim is for Part A and the TOB is other than 12X, 13X, 22X, 23X, 71X, 72X, 76X, 77X, and 85X,
• Other, non-telehealth services are billed on the same claim. In these cases, none of the services on the claim are processed.

In returning Part B claims, your MAC will use the following messaging:
• Claims Adjustment Reason Code (CARC) 16: (Claim/service lacks information or has submission/billing error(s) which is needed for adjudication) and
• Remittance Advice Remark Code (RARC) N763 (The demonstration code is not appropriate for this claim; resubmit without a demonstration code.)
• Group Code: CO (Contractual Obligation)

Saturday, March 28, 2020

Hospital Acquired conditions (HAC) CATAGORIES AND billing guidelines

Hospital Acquired Conditions (HAC) are serious conditions that patients get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions. UnitedHealthcare Medicare Advantage doesn't pay for any of these conditions, and patients can't be billed for them, if acquired while in the hospital. UnitedHealthcare Medicare Advantage will only pay for these conditions if they were present on admission to the hospital.

Effective October 1, 2015, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Version 33 Hospital Acquired Condition (HAC) list replaced the ICD-9-CM Version 32 HAC list.

HAC Categories:

01- Foreign Object Retained Following Surgery
02- Air Embolism
03- Blood Incompatibility
04- Stage III and IV Pressure Ulcers
05- Falls and Trauma
06- Catheter-Associated Urinary Tract Infection (UTI)
07- Vascular Catheter-Associated Infection
08- Surgical Site Infection (SSI) –Mediastinitis Following Coronary Artery Bypass Graft (CABG)
09- Manifestations of Poor Glycemic Control
10- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) With Total Knee or Hip Replacement
11- Surgical Site Infection (SSI) Following Bariatric Surgery for Obesity
12- Surgical Site Infection (SSI) Following Certain Orthopedic Procedures of Spine, Neck, Shoulder or Elbow
13- Surgical Site Infection (SSI) Following Cardiac Implantable Electronic Device (CIED) Procedures
14- Iatrogenic Pneumothorax w/ Venous Catheterization

Present on Admission Guidelines

To group diagnoses into the proper Diagnosis-related group (DRG), CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Collection of POA indicator data is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision as well as for broader public health uses of Medicare data. Use the UB-04 Data Specifications Manual and the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each "principal" diagnosis and "other" diagnoses codes reported on claim forms UB-04 and 837 Institutional.

The POA Indicator guidelines are not intended to provide guidance on when a condition should be coded, rather to provide guidance on how to apply the POA Indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA Indicator should be assigned to all diagnoses that have been coded.

A joint effort between the health care provider and the coder is essential to achieve accurate and complete documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis.

The provider, a provider's billing office, third party billing agents and anyone else involved in the transmission of this data shall insure that any re-sequencing of diagnosis codes prior to transmission to CMS also includes a re-sequencing of the POA Indicators

General POA Reporting Requirements

** POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.

** POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.

** A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an "other diagnosis."

** Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider.

** If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.

 CMS POA Indicator Reporting Options, Description, and Payment Indicator Description Medicare Payment
Y Diagnosis was present at time of inpatient admission. Payment is made for condition when an HAC is present
N Diagnosis was not present at time of inpatient admission. No payment is made for condition when an HAC is present
U Documentation insufficient to determine if condition was present at the time of inpatient admission. No payment is made for condition when an HAC is present
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Payment is made for condition when an HAC is present
1 Unreported/Not used. Exempt from POA reporting. This code is the equivalent of a blank on the UB-04, it was determined that blanks were undesirable when submitting this data via the 4010A.

NOTE: The number “1” POA Indicator should not be applied to any codes on the HAC list.  Exempt from POA reporting

Paper Claims

On the UB-04, the POA indicator is the eighth digit of Field Locator (FL) 67, Principal Diagnosis, and the eighth digit of each of the Secondary Diagnosis fields, FL 67 A-Q. In other words, report the applicable POA indicator (Y, N, U, or W) for the principal and any secondary diagnoses and include this as the eighth digit; leave this field blank if the diagnosis is exempt from POA reporting.

Electronic Claims

Submit the POA indicator on the 837I in the appropriate Health Care Information Codes segment as directed by the “UB04 Data Specifications Manual.

Reimbursement Guidelines

For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.

The Present on Admission Indicator Reporting provision applies only to IPPS hospitals. CMS also required hospitals to report POA information for both primary and secondary diagnoses when submitting claims for discharges on or after October 1, 2007.

Q: Do the POA and HAC programs apply to outpatient or ambulatory surgery services?
A: No, this program is only for inpatient acute care admissions.

Q: If the POA indicator is not on the claim, will the claim be returned?
A: Beginning with claims with discharges on or after October 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, the claim will be returned to the hospital for correct submission of POA information

Tuesday, February 18, 2020

Occurrence code, special program indicator list

OCCURRENCE CODE/DATE ( Form Field 31a - 34B) – Enter the applicable code and associated date to identify significant events relating to this bill that may affect processing. Dates are entered in an MMDDYY format. A maximum of eight codes and associated dates can be entered.

Required, if applicable.

The IHCP uses the following occurrence codes:

Occurrence Codes Code Description

01 Auto accident
02 No-fault insurance involved – Including auto accident or other
03 Accident or tort liability
04 Accident or employment related
05 Other accident
06 Crime victim
25 Date benefits terminated by primary payer
27 Date home health plan established or last reviewed
42 Date of discharge – This code is used to show the date of live discharge from the
hospital confinement being billed, from a long-term care facility, or from home health
care or hospice, as appropriate.
52 Certification/recertification date – This code is used to show that an initial examination
or initial evaluation is being billed in a hospital setting. This code bypasses certain PA
editing. Details can be found in the applicable sections of the IAC.
55 Date of death – This code is used to show the date of death.
73 Benefit eligibility – This code is used to bill for home health overhead – One per day.

Special Program Indicators

A0 Special Zip Code Reporting-Ambulance
A3 Special Federal Funding
A5 Disability
A6 PPV/Medicare Pneumococcal Pneumococcal/Influenza
A7 Induced Abortion - Danger to Life
A9 Second Opinion Surgery
AA Abortion performed due to Rape
AB Abortion performed due to Incest
AC Abortion performed due to serious fetal genetic defect, deformity, abnormality
AD Abortion performed due to life endangering condition
AE Abortion performed due to physical health of mother that is not life endangering
AF Abortion performed due to emotional/psychological health of mother
AG Abortion performed due to social economic reasons
AH Elective abortion
AI Sterilization
AJ Payer responsible for Co-payment
AK Air ambulance required
AL Specialized treatment/bed unavailable
AM Non-emergency Medically Necessary Stretcher Transport Required
AN Preadmission Screening Not Required
AO-AZ Reserved for National Assignment
B0 Medicare coordinated care demonstration program
B1 Beneficiary is ineligible for demonstration program
B2 Ambulance-CAH exempt from fee schedule if not exempt CAH don’t use B2
B3 Pregnancy indicator
B4 Admission Unrelated to Discharge - Admission unrelated to discharge on same day. This code is
for discharges starting on January 1, 2004. Effective January 1, 2005
BP Gulf Oil Spill Related, all services on claim
DR Disaster Related
G0 Distinct Medical visit - multiple medical visits occurred same day in same revenue center - Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 (zero) allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0 (zero).

Saturday, August 10, 2019

Condition code G0 - Billing Guideliens

Condition code G0 Distinct Medical Visit Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.

Proper Reporting of Condition Code G0

Hospitals should report condition code G0 in Form Locators 24-30 on the UB-04 claim form, the electronic equivalent, when multiple medical visits occur on the same day in the same revenue center, but the visits were distinct and independent visits.


Beneficiary presents to the emergency room in the morning for a broken arm, then later that same day presents for chest pain.

On the first claim, report the first ER visit (revenue code 045X plus E/M code) with all ancillary services rendered on that day.

On the second claim, report only the unrelated ER visit (revenue code 045X plus E/M code) with condition code G0 and modifier 27. All other charges are reported on the first claim.

Proper reporting of condition code G0 allows for proper payment under the Outpatient Prospective Payment System. The Outpatient Code Editor contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of condition code G0.

Multiple Medical Visits billing Guideline

• Claims for separate and distinct medical visits for the same beneficiary on the same date and by the same provider must have condition code G0 (zero).
• Without this code subsequent claims will deny.
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.

Multiple Unrelated Visits on the Same Date of Service

Forward Health defines a related visit as one whose primary diagnosis matches the primary diagnosis of a subsequent visit. When billing one or more separate, unrelated visits that occur on the same DOS as an outpatient continuous visit, Forward Health recommends providers do the following: ? Submit separate claims for each visit. Include condition code G0 (the letter G and the digit zero) on the second claim submitted and send it to Written Correspondence for special handling. To do this, attach the Written Correspondence Inquiry form, F-01170 (07/12), to the paper claim or adjustment form and indicate “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the Other Information field of the form.

* If a claim that indicates the G0 condition code also requires consideration for an exception to the submission deadline, submit a completed Timely Filing Appeals Request form, F-13047 (07/12), for each claim, entering “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the free format field near the bottom of the form.

For example, a member comes in to the emergency room (ER) on the morning of January 8, 2012, with a concussion and returns home once treated. He returns to the ER later that same night with a high fever and vomiting and is kept over midnight for observation. In this situation, the provider is encouraged to bill the two visits on two separate claims and to differentiate the visits using condition code G0 on the second claim submitted, following the special handling instructions stated previously. This allows Forward Health to reimburse both visits and pay two access payments to the provider, if applicable.

Note: The special handling instructions listed above apply to claims or adjustments with DOS between January 1, 2010, and March 31, 2013. Claims and adjustments with DOS on and after April 1, 2013, will not require special handling for the G0 condition code; these claims will be processed using the new Enhanced Ambulatory Patient Groups (EAPG) reimbursement methodology for outpatient hospital services.

Multiple Medical Visits

• Claims for separate and distinct medical visits for the same beneficiary on the same date and by the same provider must have condition code G0 (zero).
• Without this code subsequent claims will deny.
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.

Use of Modifier –25 and Modifier 27 in the Hospital Outpatient Prospective Payment System (OPPS)

This Program Memorandum (PM) provides clarification on reporting modifier –25 and modifier –27 under the hospital OPPS.

The Current Procedural Terminology (CPT) defines modifier 25 as “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Modifier –25 was approved for hospital outpatient use effective June 5, 2000.

The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001. Although HCFA will accept modifier –27 for OPPS claims, this modifier will not replace condition code G0. The reporting requirements for condition code G0 have not changed. Continue to report condition code G0 for multiple medical visits that occur on the same day in the same revenue centers. For further clarification on both modifiers, refer to the CPT 2001 Edition. Below are general guidelines in reporting modifiers –25 and –27 under the hospital OPPS.

A. Modifier –27 should be appended only to E/M service codes within the range of 92002- 92014, 99201-99499, and with HCPCS codes G0101 and G0175.

B. Hospitals may append modifier –27 to the second and subsequent E/M code when more than one E/M service is provided to indicate that the E/M service is “separate and distinct E/M encounter” from the service previously provided that same day in the same or different hospital outpatient setting.

C. When reporting modifier 27, report with condition code G0 when multiple medical visits occur on the same day in the same revenue centers.

As is true for any modifier, the use of modifiers –25 and –27 must be substantiated in the patient’s medical record.

Fiscal Intermediaries should forward this PM electronically to providers and place on their web site. This PM should also be distributed with your next regularly scheduled bulletin. 

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