Medicare Compliance & Reimbursement

If you need a way to override a medically unlikely edit, HCPCS offers you a new modifier effective Jan. 1.

Starting in January, the medically unlikely edits (MUEs) will limit the number of units of a particular code that your physician can bill. To avoid MUE-related denials, you can now append new HCPCS modifier GD (Units of service exceed MUE value but represent medically necessary services) to your claim.

CMS has not yet announced whether this modifier will apply to both CPT and HCPCS codes. But assuming it does, modifier GD could come in handy for many practices.

"Suppose the surgeon bills for two appendectomies because the patient has a native one and one attached to his transplanted organ," says Suzan Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh Physicians Department of Surgery. "This would be a medically unlikely scenario, however, one that happened nonetheless."

HCPCS will no longer include modifiers QA (FDA investigational device exemption), QR (Item/service provided in a Medicare study) or QV (Item/service provided as routine care in a clinical trial).