Medicare Compliance & Reimbursement

Question: I thought Medicare does not pay extra for physical status modifiers or qualifying circumstances add-on codes, but a colleague told me they are billing these and receiving payment. Do you know if Medicare has changed its policy?

Florida Subscriber

Answer: Traditional Medicare does not recognize qualifying circumstances for additional payment, nor does it recognize or pay additional units for physical status — everything is bundled into the payment for the anesthesia service.

It’s possible your colleague was referring to Medicare Advantage or Medicare replacement plans, which might provide coverage. Some of these plans follow Traditional Medicare guidelines and do not pay for qualifying circumstances or physical status, whereas others may allow additional payment.

When you’re not sure whether the insurer will pay, the best course of action is to submit the information on the claim — you can’t receive payment for extenuating circumstances not reported or services that aren’t billed.