Page 46 - Medicare Benefit Policy Manual

The way this would work in the fractured leg example (see previous paragraph) is that the
physician or practitioner would bill Medicare for the setting of the fractured leg with the
emergency opt-out HCPCS modifier (GJ) and the surgical care only modifier (54) to
ensure that Medicare does not pay the Evaluation and Management (E&M) that is in the
global fee for the procedure. The physician or practitioner would then either have the
beneficiary sign the private contract or refer the beneficiary to a Medicare physician or
practitioner who would bill Medicare using the post op only modifier to be paid for the
post op care in the global period.

If the beneficiary continues to be in a condition that requires emergency or urgent care
(i.e., unconscious or unstable after surgery for an aneurysm) follow up care would
continue to be paid under emergency or urgent care until such time as the beneficiary no
longer needed such care. In the absence of incontrovertible evidence, CMS recommends
accepting what the physician or practitioner says via the modifiers and doing post-pay
records review of frequent users of the opt-out modifier.

40.29 - Definition of Emergency and Urgent Care Situations
(Rev. 206, Issued: 04-10-15, Effective: 07-13-15, Implementation: 07-13-15)

Emergency care services means inpatient or outpatient hospital services that are
necessary to prevent death or serious impairment of health and, because of the danger to
life or health, require use of the most accessible hospital available and equipped to
furnish those services. Congress intended that the term “emergency or urgent care
services” not be limited to emergency services since they also included “urgent care
services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished
within 12 hours in order to avoid the likely onset of an emergency medical condition.
For example, if a beneficiary has an ear infection with significant pain, CMS would view
that as requiring treatment to avoid the adverse consequences of continued pain and
perforation of the eardrum. The patient’s condition would not meet the definition of
emergency medical condition because immediate care is not needed to avoid placing the
health of the individual in serious jeopardy or to avoid serious impairment or dysfunction.
However, although it does not meet the definition of emergency care, the beneficiary
needs care within a relatively short period of time (which CMS defines as 12 hours) to
avoid adverse consequences, and the beneficiary may not be able to find another
physician or practitioner to provide treatment within 12 hours.

40.30 - Denial of Payment to Employers of Opt-Out Physicians and
Practitioners
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

If an opt-out physician or practitioner is employed in a hospital setting and submits bills
for which payment is prohibited, the Medicare contractor usually detects and investigates
the situation. However, in some instances an opt-out physician or practitioner may have
a salary arrangement with a hospital or clinic or work in a group practice and may not
directly submit bills for payment. If the Medicare contractor detects this situation, it must