Condition code G0 - Billing Guideliens

Condition code G0 Distinct Medical Visit Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits. An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain. Proper reporting of Condition Code G0 allows for payment under OPPS in this situation. The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.


Proper Reporting of Condition Code G0

Hospitals should report condition code G0 in Form Locators 24-30 on the UB-04 claim form, the electronic equivalent, when multiple medical visits occur on the same day in the same revenue center, but the visits were distinct and independent visits.


Example

Beneficiary presents to the emergency room in the morning for a broken arm, then later that same day presents for chest pain.

On the first claim, report the first ER visit (revenue code 045X plus E/M code) with all ancillary services rendered on that day.

On the second claim, report only the unrelated ER visit (revenue code 045X plus E/M code) with condition code G0 and modifier 27. All other charges are reported on the first claim.

Proper reporting of condition code G0 allows for proper payment under the Outpatient Prospective Payment System. The Outpatient Code Editor contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of condition code G0.




Multiple Medical Visits billing Guideline

• Claims for separate and distinct medical visits for the same beneficiary on the same date and by the same provider must have condition code G0 (zero).
• Without this code subsequent claims will deny.
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.



Multiple Unrelated Visits on the Same Date of Service

Forward Health defines a related visit as one whose primary diagnosis matches the primary diagnosis of a subsequent visit. When billing one or more separate, unrelated visits that occur on the same DOS as an outpatient continuous visit, Forward Health recommends providers do the following: ? Submit separate claims for each visit. Include condition code G0 (the letter G and the digit zero) on the second claim submitted and send it to Written Correspondence for special handling. To do this, attach the Written Correspondence Inquiry form, F-01170 (07/12), to the paper claim or adjustment form and indicate “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the Other Information field of the form.

* If a claim that indicates the G0 condition code also requires consideration for an exception to the submission deadline, submit a completed Timely Filing Appeals Request form, F-13047 (07/12), for each claim, entering “Update 2013-09” and “Condition code G0 for a subsequent outpatient visit” in the free format field near the bottom of the form.

For example, a member comes in to the emergency room (ER) on the morning of January 8, 2012, with a concussion and returns home once treated. He returns to the ER later that same night with a high fever and vomiting and is kept over midnight for observation. In this situation, the provider is encouraged to bill the two visits on two separate claims and to differentiate the visits using condition code G0 on the second claim submitted, following the special handling instructions stated previously. This allows Forward Health to reimburse both visits and pay two access payments to the provider, if applicable.

Note: The special handling instructions listed above apply to claims or adjustments with DOS between January 1, 2010, and March 31, 2013. Claims and adjustments with DOS on and after April 1, 2013, will not require special handling for the G0 condition code; these claims will be processed using the new Enhanced Ambulatory Patient Groups (EAPG) reimbursement methodology for outpatient hospital services.



Multiple Medical Visits

• Claims for separate and distinct medical visits for the same beneficiary on the same date and by the same provider must have condition code G0 (zero).
• Without this code subsequent claims will deny.
• Denied lines will receive the edit “0110 – Date bundling not allowed” for subsequent claims that do not have condition code G0.




Use of Modifier –25 and Modifier 27 in the Hospital Outpatient Prospective Payment System (OPPS)

This Program Memorandum (PM) provides clarification on reporting modifier –25 and modifier –27 under the hospital OPPS.

The Current Procedural Terminology (CPT) defines modifier 25 as “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Modifier –25 was approved for hospital outpatient use effective June 5, 2000.

The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001. Although HCFA will accept modifier –27 for OPPS claims, this modifier will not replace condition code G0. The reporting requirements for condition code G0 have not changed. Continue to report condition code G0 for multiple medical visits that occur on the same day in the same revenue centers. For further clarification on both modifiers, refer to the CPT 2001 Edition. Below are general guidelines in reporting modifiers –25 and –27 under the hospital OPPS.

A. Modifier –27 should be appended only to E/M service codes within the range of 92002- 92014, 99201-99499, and with HCPCS codes G0101 and G0175.

B. Hospitals may append modifier –27 to the second and subsequent E/M code when more than one E/M service is provided to indicate that the E/M service is “separate and distinct E/M encounter” from the service previously provided that same day in the same or different hospital outpatient setting.

C. When reporting modifier 27, report with condition code G0 when multiple medical visits occur on the same day in the same revenue centers.

As is true for any modifier, the use of modifiers –25 and –27 must be substantiated in the patient’s medical record.

Fiscal Intermediaries should forward this PM electronically to providers and place on their web site. This PM should also be distributed with your next regularly scheduled bulletin.