Medicare Updates: GA Modifier Processing, Acute Care Transfer Rule, Clinical Trials Billing

on Thursday, 23 September 2010. All News Items

Per CMS Change Request (CR) 7106, services submitted with the modifier –GA on institutional claims will not be subject to automatic denial until further notice. Previous CR 6563, regarding “Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs)” directed Medicare contractors processing institutional claims to automatically deny line items submitted with the modifier –GA effective April 1, 2010. In response to providers’ concerns and review of applicable program policies, such denials have been suspended at the direction of CMS. For more information, see MLN Matters Article MM7106.

The 2011 IPPS Final Rule included changes to the acute care transfer rule which previously did not apply to transfers to non-participating hospitals or critical access hospitals (CAHs).   Effective for discharges on or after October 1, 2010, IPPS hospitals that transfer patients to a non-participating acute-care hospital (patient status code 02) or a CAH (patient status code 66) will be subject to the transfer policy. System changes needed to accommodate this change (transfers to CAHs) will occur in April 2011. For more information on the transfer rule change and other 2011 IIPPS changes, see MLN Matters Article MM7134.  Please note that a list of the 2011 Post-Acute Care Transfer DRGs is now available under the Resource Library on the MMP, Inc. website at

CMS Transmittal 2052 (CR 6776) corrects institutional billing requirements for clinical trial claims. Institutional providers billing inpatient and outpatient clinical trial services must report ICD-9-CM Diagnosis code of V70.7 (Examination of participant in clinical trial) in the secondary position (or in the primary position if the patient is a healthy, control group volunteer) and a condition code 30 regardless of whether all services are related to the clinical trial or not. Since Healthy Control Group Volunteers, by definition, do not have any underlying conditions, providers need to report ICD-9-CM Diagnosis code, V70.7 (V70.5 for dates of service September 19, 2000 through December 31, 2001), as the primary diagnosis instead of the secondary diagnosis, as no primary diagnosis exists. For more information, see MLN Matters Article MM6776.

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