Modifier Updates

Modifier GJ (2021)


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

In an emergency or urgent care situation, a provider may treat a Medicare beneficiary with whom he or she does not have a private contract and bill Medicare for such treatment. The provider may not charge the beneficiary more than the limiting charge and must submit a claim to Medicare on the beneficiary’s behalf. Medicare payment will be made to the beneficiary for covered services in this situation if the claim is unassigned. In order to submit an assigned claim and be paid directly by Medicare for such services, the opt out provider would need to complete a CMS-855 enrollment form to apply for enrollment in the Medicare program. (This would not affect the provider’s opt out status for purposes of other services.)

Opt out providers use GJ Modifier with the procedure code to identify services that were emergency or urgent when there was no private contract in effect with the beneficiary at the time the services were performed.

This modifier must be used on claims for services rendered by an opt-out physician/ practitioner for an emergency/urgent service.

If the physician or practitioner did not submit GJ Modifier national HCPCS modifier, then the carrier would deny the claim so that the beneficiary can appeal.

Return to List of All Modifiers

Recent Posts

  • ICD 11

Certain Disorders Involving The Immune System – Definitions & ICD 11 Codes

Definitions of Certain Disorders Involving The Immune System: Disorders in which disturbed immune regulation plays…

  • ICD 11

Immune System Disorders Involving White Cell Lineages – Definitions & ICD 11 Codes

Coded Elsewhere: Immunodeficiencies with predominantly antibody defects (4A01.0)Combined immunodeficiencies (4A01.1)Defects in the complement system (4A00.1)Diseases…

  • ICD 11

Allergic Or Hypersensitivity Conditions – Definitions & ICD 11 Codes

Definition of Allergic Or Hypersensitivity Conditions: Allergy is a hypersensitivity reaction initiated by a proven…

  • ICD 11

Autoinflammatory Disorders – Definitions & ICD 11 Codes

Coded Elsewhere: Schnitzler syndrome (EB03) Monogenic autoinflammatory syndromes Definition of Monogenic autoinflammatory syndromes: Monogenic hereditary…

  • ICD 11

Non-Organ Specific Systemic Autoimmune Disorders – Definitions & ICD 11 Codes

Coded Elsewhere: Rheumatoid arthritis (FA20) Lupus erythematosus Definition of Lupus erythematosus: An autoimmune non-organ specific…

  • ICD 11

Primary Immunodeficiencies – Definitions & ICD 11 Codes

Primary immunodeficiencies due to disorders of innate immunity ICD 11 Codes For Primary immunodeficiencies due…