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Modifier CG: Big Change in RHC Billing Effective OCT. 1, 2016

For RHC claims processed after 10/01/2016, CMS has issued further guidance on the appropriate use of the new CG modifier.  This guidance is available in its revised Medlearn Matters SE1611.






In April 2016, CMS instructed Rural Health Clinics to hold claims only for a billable visit shown in red on the RHC QVL until October 1, 2016, due to programming and claims processing problems. In earlier articles, CMS instructed RHCs to use modifier CG when billing the QVL codes after October 1st.  Further guidance on use of the CG modifier includes this explanation:

Beginning on October 1, 2016, the MACs will accept modifier CG on RHC claims and claim adjustments. RHCs shall report modifier CG on one revenue code 052x and/or 0900 service line per day, which includes all charges subject to coinsurance and deductible for the visit. For RHCs, the coinsurance is 20 percent of the charges. Therefore, coinsurance and deductible will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG. RHCs will continue to be paid an all-inclusive rate (AIR) per visit.

Each additional service furnished during the visit should be reported with the most appropriate revenue code and charges greater to or equal to $0.01. The additional service lines are for informational purposes only. MACs will continue to package/bundle the additional service lines, which do not receive the AIR.

When the patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day, the subsequent medical service should be billed using revenue code 052x and modifier 59. Beginning on October 1, 2016, RHCs can also report modifier 25 to indicate the subsequent visit was distinct or independent from an earlier visit furnished on the same day. When modifier 59 or modifier 25 is reported, RHCs will receive the AIR for an additional visit. This is the only circumstance in which modifier 59 or modifier 25 should be used.

Clinics should append the -CG modifier to one CPT® code line item from the qualifying visit list using either revenue code 0521 or 0900.  All other charges incurred during each separate encounter will roll up to the total charges reported with that QVL line.  Additional charges will be reported as additional line items using a charge ≥ $0.00.    The 0001 Total Charges line will appear overstated since it will include the encounter charges plus the additional line item amounts.  However, the coinsurance and deductible amounts will only be calculated from the lines appending -CG.   Preventative services should also be reported with -CG although the coinsurance and deductible will be waived if applicable to the CPT® code reported.  The -CG modifier is used even if there is only one service per day.   No other modifiers should be appended to the RHC claim except for the rare occurrence of two separate medical visits in one day.   Please email Patty Harper at pharper@inquiseek.com if you have questions about this change.



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