Chiropractic billing important questions


Question: What is the difference between the GP and GY modifiers? Do we use GP, GY and GA for physical therapy charges?
Answer: Yes, it is possible that physical therapy services could be billed with all three modifiers. (Remember that the patient does not have to sign an Advance Beneficiary Notice of Noncoverage (ABN) to be held financially responsible.)

* GP: Services delivered under an outpatient physical therapy plan of care.
Chiropractors billing for physical therapy services (CPT codes 97001–97799 and HCPCS code G0283) must bill with the appropriate modifier. Even though physical therapy billed by a chiropractor is a program exclusion, if one of the above modifiers is omitted from any of the codes referenced, the service will be rejected. This rejection would require the claim to be corrected and resubmitted.

* GY: Used to indicate an item or service statutorily excluded or it does not meet the definition of any Medicare benefit.

This modifier can be used when billing for a non-covered service to later bill to the patient’s secondary insurance for consideration (e.g., X-rays or physical therapy).

* GA: Used to indicate that an ABN is on file.
A copy of the ABN does not have to be submitted with the claim but must be made available upon request.

Question: Do we need an ABN on file for physical therapy, X-rays and exams if we are not billing Medicare? Or is it voluntary?
Answer: The only Medicare Part B benefit for chiropractors is the spinal manipulation. All services other than spinal manipulation, such as X-rays, office visits, physical therapy services, supplies or extra-spinal manipulations, are considered excluded services and are not a Medicare Part B benefit. These types of excluded services are never covered and are always the patient’s financial responsibility. Therefore, the ABN is not required to hold the patient financially responsible.

Question: Do we have to bill Medicare for physical therapy, X-rays and exams even though we know Medicare will not cover them?
Answer: These types of services do not have to be billed to Medicare because they are program exclusions. In some cases, the patient might request that you bill all services provided to Medicare for the purpose of supplemental insurance or for their records, and in this case, they should be billed.

Question: Is there a limit for the number of modifiers used?
Answer: Paper claim submitters only have the ability to bill four modifiers. However, electronic billers sometimes have the capability to bill up to eight modifiers.

Question: Does the number of visits allowed reset if there is a change in the diagnosis (i.e., the patient suffers a new injury)?

Answer: The answer is per episode. If the patient had an acute exacerbation of a current diagnosis or had a new episode (with a new diagnosis) that was well documented in the record, consideration for the new episode/acute exacerbation would be given when the claim is reviewed by the Medical Review department
Question: There were concerns about the physical therapy codes being rejected when billed with the GP and GY modifier.
Answer: These situations need to be evaluated on a claim-by-claim basis. Please contact the Part B Provider Contact Center at (866) 280-6520 for assistance.

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