Wiki Medicare and Workers Comp modifier

[aburger]

I work In Orthopedics and we are currently having an issue with a patient who's Physical therapy visits are being denied based off a WC claim that is completely unrelated. Today we were told to add a modifier that shows medicare it is not a work related injury because the checked box just will not do. Also we have checked and made sure that the DX codes are not causing an issue as well. Does anyone have any help with how we should handle this? Or what that magical modifier is?

 

[TThivierge]

Hi Aburger
I'd use the modifier GA means liability waive on individual case lets the Medicare payer know WC not covering this problem any longer. Then send cover letter explain pt PREVIOUSLY treated due to Work com but no longer the case. Also in billing phy therapy need add referring doctor/provider name on claim ,other modifier GO vs GN or GP which ever applies, laterality modifiers if required, and minutes in the medical record too.
I hope this helps you. Hey did the Medicare pt sign a ABN too....they have modifier for that too
I hope this data helps you
Lady T

 

[lgardner]

just a clarification..

GA modifier indicates that it is expected that Medicare will deny a service AND an ABN has been signed and is on file.
if no ABN is on file, then you can use modifier GZ, but i don't know if it is appropriate in this situation, or not.

per CMS (emphasis added by me):
https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2148cp.pdf
The GA modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. (See http://www.cms.hhs.gov/medlearn/refabn.asp for additional information on use of the GA modifier and ABNs.)

The GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit.
The GZ modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

 

[blsorrell]

Go to wpsgha.com. In the search, type in 'not workers comp'. It states, if service is truly unrelated then to put a comment 'not workers compensation'.
On a 1500 form, I think that is box 19, but it has been awhile since I have used it.

 

[suki_26]

Being in Primary Care and NY we see lots of NF and WC related denials. I would think you could handle it the same way we do for PT .

I usually go on the Medicare MAC website. For us its NGSCONNEX. I do a claim redetermination and upload the medical records for that Date of service and put the explanation that this DX was not related to any open WC or NF claim. It takes about 60 days to get a redetermination reply but this way I know the info and proof have been uploaded directly to Medicare. There isn't a modifier that I am aware of and I find that the computer adjudication systems don't read our box 19 notes. ( I still use them though)