Page 45 - Medicare Benefit Policy Manual

practitioner. Hence, they are covered services furnished by a nonparticipating physician
or practitioner, and the rules in effect absent the opt-out would apply in these cases.
Specifically, the physician or practitioner may choose to take assignment (thereby
agreeing to collect no more than the Medicare deductible and coinsurance based on the
allowed amount from the beneficiary) or not to take assignment (and to collect no more
than the Medicare limiting charge), but the practitioner must take assignment under
§1842(b)(18) of the Act.

Therefore, in this circumstance the physician or practitioner must submit a completed
Medicare claim on behalf of the beneficiary with the appropriate HCPCS code and
HCPCS modifier that indicates the services furnished to the Medicare beneficiary were
emergency or urgent care services and the beneficiary does not have a private contract
with the physician or practitioner. If the physician or practitioner did not submit the GJ
national HCPCS modifier, then the Medicare contractor must deny the claim so that the
beneficiary can appeal.

GJ = Opt-out physician/practitioner EMERGENCY OR URGENT SERVICES

This modifier must be used on claims for services rendered by an opt-out physician/
practitioner for an emergency/urgent care service. The use of this modifier indicates that
the service was furnished by an opt-out physician/practitioner who has not signed a
private contract with a Medicare beneficiary for emergency or urgent care items and
services furnished to, or ordered or prescribed for, such beneficiary on or after the date
the physician/practitioner opted out.

The Medicare contractor must deny payment for emergency or urgent care items and
services to both an opt-out physician or practitioner and the beneficiary if these parties
have previously entered into a private contract, i.e., prior to the furnishing of the
emergency or urgent care items or services but within the physician’s or practitioner’s
current 2-year period.

Under the emergency and urgent care situation where an opt-out physician or practitioner
renders emergency or urgent service to a Medicare beneficiary (e.g., a fractured leg) who
has not entered into a private agreement with the physician or practitioner, as stated
above the physician or practitioner is required to submit a claim to Medicare with the
appropriate modifier (GJ and 54 as discussed further below) and is subject to all the rules
and regulations of Medicare, including the limiting charge. However, if the opt-out
physician or practitioner asks the beneficiary, with whom the physician or practitioner
has no private contract, to return for a follow up visit (e.g., return within 5 to 6 weeks to
remove the cast and examine the leg) the physician or practitioner must ask the
beneficiary to sign a private contract. In other words, once a beneficiary no longer needs
emergency or urgent care (i.e., non-urgent follow up care), Medicare cannot pay for the
follow up care and the physician or practitioner can and must, under the opt-out affidavit
agreement, ask the beneficiary to sign a private contract as a condition of further
treatment.