decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Modifier -GJ / BBA
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Article Overview
This article explains Medicare policy for physicians and practitioners who have opted out of Medicare, with emphasis on when emergency or urgent services may be billed, the role of private contracts, and the related documentation and filing requirements. It is relevant to coders, compliance staff, and providers who handle Medicare claims involving opt-out arrangements and emergency care exceptions. The article also addresses the surrounding regulatory context and mentions related modifier use for follow-up surgical care.
Why This Topic Matters
Understanding this guidance helps avoid improper claim handling in opt-out scenarios and supports compliance with Medicare’s rules for emergency or urgent services, private contracting, and required administrative steps.
Article Sections
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Overview of private contracts and opt-out status
Introduces the policy background for Medicare opt-out arrangements and private contracting. Summarizes the general relationship between the beneficiary, the physician or practitioner, and Medicare.
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Emergency and urgent care billing
Discusses circumstances in which opt-out physicians or practitioners may treat beneficiaries in emergency or urgent situations. Covers the general claim handling context for these services.
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Modifier -GJ and related follow-up care
Describes the article’s focus on modifier use in connection with opt-out emergency or urgent services and follow-up surgical care. Also notes the connection to claim submission for this setting.
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Definition of emergency and urgent care situations
Provides the regulatory context used to identify emergency or urgent care situations. References the federal framework discussed in the article.
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Contents and validity of private contracts
Outlines the required elements of a private contract and the conditions affecting its validity. Summarizes the beneficiary acknowledgment and timing requirements discussed in the article.
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Affidavit requirement
Notes the administrative filing step referenced for physicians or practitioners who opt out. Identifies the Medicare carrier as the receiving entity.
What You Will Learn
- How Medicare opt-out status affects private contracting
- When emergency or urgent services are discussed in the context of opt-out providers
- What types of documentation requirements are associated with private contracts
- What administrative filing step is mentioned for opt-out physicians or practitioners
- How the article frames modifier use in relation to opt-out emergency services
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Physicians and practitioners
- Revenue cycle teams
Modifiers Discussed
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