CG Modifier

10/26/2016

CMS has produced an FAQ document that addresses many of the questions/scenarios relative to the use of the CG modifier that have been raised on this listserve.
I strongly encourage you to review this document.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Reporting-FAQs.pdf

As will see when you review the document, there is an FAQ that addresses one of the scenarios you posed by Lori Donals:

Q. If a medical service and a preventive service are furnished on the same day, should modifier CG be reported with both services?

A. No. Modifier CG should be reported only with the medical service HCPCS code that represents the primary reason for the medically necessary face-to-face visit when medical and preventive services are furnished on the same day.
To your specific examples.

Scenario One: It should be the line (CPT code) that was the primary medical reason for the visit. So if in the scenario you are using, the primary medical reason the patient came into the RHC was for skin lesion removal (CPT 17000) and you also performed the introductory to Medicare physical (G0402). The CG modifier goes on the line where you report the 17000.

In this specific situation, you would get two AIR payments. One for the medically necessary visit (17000) and one for the IPPE (G0402). The coinsurance would be applied to the lesion removal (medically necessary visit) and there would be no coinsurance for the IPPE (it’s waived for this service).

Scenario two: Again, the CG modifier goes on the line that is the primary reason the patient came into the RHC for a visit. Because both are preventive visits, there is no “medical” or “mental health” visit. So here, you get to choose. Did the patient come in for the IPPE (G0402) or the Well Woman exam (G0101) and you combined them into the same visit? Either way, you pick one that is “primary” and you put the CG modifier on that line.

Typically, only one line of the claim requires the CG modifier. The principle exception to this is if you provide BOTH a Medicare covered medical visit and a Medicare covered mental health visit to the same patient during the same visit, then both lines would have the CG modifier. This is typically going to be the only time you’d have the CG modifier on the claim more than one.

Hope this helps.

Bill Finerfrock
202-544-1880
bf@capitolassociates.com

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