Does anyone know the
correct use for the GF modifer - I just started coding for ARNPs for Medicare. This modifer has me a little confused. Can anyone help? When would this modifer be used? They see patients that are in the hospital setting - inpatient and observation.
The Importance of Modifiers in Medicare Critical Access Hospital Billing
Critical Access Hospitals (CAHs) participating as a Medicare provider have the prerogative to elect an optional payment method referred to as “Option” or “Method” II.
This payment methodology relates to outpatient services only. CAHs meeting the criteria for participation may elect this payment structure and are paid 101 percent for their cost-based facility services, plus 115 percent of the Medicare physician fee schedule for professional services.
The Medicare Internet Only Manual (IOM) 100-04, Chapter 4, Section 250 states that a CAH billing for the non-physician practitioner (NPP) services under Option II must report a CPT modifier describing the credentials of the performing practitioner. This reference further explains that payment for non-physician practitioners will be made at 115 percent of the allowable amount payable under the Medicare physician fee schedule; in other words at a reduced rate of 115% of the 85% (NPP rate).
Hospitals submitting professional billing for other than the Option II Critical Access hospital do so via CMS Form 1500. The hospital completes CMS Form 1500 claim form and identifies the rendering provider of service by reporting the professional’s national provider identification (NPI) number. Within the Part B Medicare processing environment the rendering provider identification number is linked to the specific practitioner’s profile which is a part of the claims processing system. This profile recognizes the practitioner’s professional qualifications. This assures that the mid-level practitioner being billed on the CMS 1500 claim is not only identified but reimbursed the correct payment calculation. For the CAH Option II hospital billing for the outpatient professional services only the qualifying CPT modifier used to describe the credentials of the NPP will assure the correct payment. Professional services reported on the UB claim without a modifier are assumed by Medicare to be rendered by a physician
The non-physician practitioner professional services require one of the following modifiers:
GF – Service rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA).
SB - Services rendered in a CAH by a nurse midwife.
AH - Services rendered in a CAH by a clinical psychologist.
CAH Option II providers bill for outpatient professional services using the UB04 / 837I claim format. The UB uses a revenue code to identify the service’ the professional services are reported using the 096x-098x series. This revenue requires the reporting of a CPT code which describes the services provided. The CPT code is used to determine the allowable payment from the Medicare physician fee schedule. Modifier reporting is the key to assuring that the payment for outpatient professional services billed by a Critical Access Hospital electing Option II is appropriate.