Practice Management & Allied Staff News & Materials
Reminder to OMSs Who Have Opted Out of Medicare
August 16th, 2006
As many OMSs who have opted out of Medicare are aware, Medicare will pay for emergency or urgent care services furnished to Medicare beneficiaries who have not signed a private contract with the OMS prior to the emergency service.
This is the only exception to the Medicare policy which prohibits physicians who have opted out from submitting claims to Medicare. When an OMS who has opted out treats a Medicare beneficiary who has not signed a private contract in an emergency situation, the OMS must submit the claim on the patient's behalf. The claim should be submitted with the HCPCS modifier "GJ — Opt Out physician or practitioner emergency or urgent service". The "GJ" indicates to Medicare that the service provided was rendered by an OMS who has opted out and has not signed a private contract with this particular beneficiary therefore the service should be submitted and paid. Keep in mind that Medicare's typical allowed amounts and limiting charges apply.
In the event that a follow up visit is required, the surgical procedure should also contain the modifier 54- "Surgical Care Only" so that the E/M that is in the global fee for the procedure is not paid. The patient may then sign a private contract for any post-operative care rendered in the office or may be referred to Medicare provider who would bill Medicare using modifier "55- Post Operative Management Only". If a Medicare patient with whom a signed private contract has been obtained is treated in the emergency room a claim would not need to be submitted as the private contract is valid for any and all services rendered to the patient within the OMS's opt out period.