Urgent: New CMS Billing Rules Effective 01/01/2018

Please note that CMS implemented a new rule to requires doctors of chiropractic to add a 2nd modifier when billing Medicare for non-covered physical medicine services.


Doctors of chiropractic often utilize the 'GY' modifier when billing for medically-necessary non-covered services for your patients (non-covered services under CMS guidelines include such items as examinations and physical medicine services such as ultrasound, therapeutic exercise, electrical muscle stimulation).  As a reminder, the GY modifier is used for services that are statutorily excluded or do not meet the definition of any Medicare benefit.  This is particularly important when the doctor of chiropractic require the Medicare 'PR' denial (patient responsibility) for secondary insurance claim processing.

What's new?  

All claims received by CMS/NGS ON OR AFTER 1/1/18 must include a secondary modifier (GN, GO, or GP) for non-covered physical medicine services to indicate whether the services fall into the physical therapy (PT), occupational therapy (GO), or speech therapy (GN) therapy caps (financial benefit limitations).  When contacting NGS, we were advised to add the 'GP' modifier to the 'GY' modifier when billing for non-covered physical therapy services.  PLEASE ENSURE YOUR OFFICE ADDS THE 2ND GP MODIFIER FOR PHYSICAL THERAPY SERVICES OR THOSE SERVICES WILL BE DENIED AS 'CO' (contractual obligation) LIMITING YOUR ABILITY TO BILL FOR THE NON-COVERED SERVICE OR POTENTIALLY RECEIVING PAYMENT FROM A SECONDARY CARRIER.

The NYSCA understands that CMS/NGS does not cover 'physical therapy' services rendered by doctors of chiropractic, and that doctors of chiropractic are not physical therapists'; however, we have been advised by NGS that we are required to bill with the 'GP' modifier in addition to the GY modifier (or any other appropriate modifier that may apply to your patient. 

Please note this is new information from CMS as interpreted by NGS.  New processes may be subject to future change.  We are not sure how NGS will apply the value of these non-covered services to a financial cap for physical therapy services.  In addition, other rules may become applicable (e.g., once the patient reaches the physical therapy financial cap), which will become impractical for us to track as individual practitioners, particularly for patients seeking services from a physical therapist. 

As always, please ensure you are aware of the appropriate use of both required modifiers (e.g., GA, GY, GZ, etc.) and the use of the CMS Advanced Beneficiary Notice (ABN).  Take the time to review any CMS/NGS updates your may receive (which may only be via email).  We will post additional updates relative to this rule as we receive them and discuss with NGS.   Please also take the time to advise the NYSCA if you experience difficulties with this new policy and process.

For more information regarding this important change, please see the following CMS link (this information is also available on NGS's web site)https://www.cms.gov/.../MM10176.pdf

Happy New Year....

NYSCA Insurance Committee


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