2025 HCPCS code GJ
(Active) Effective Date: N/A Revision Date: N/A "opt out" physician or practitioner emergency or urgent service - Modifiers for HCPCS codes Feed
This modifier is used when a non-participating physician provides emergency or urgent services to a Medicare patient.
Medical necessity must be clearly established for services billed with modifier GJ. The documentation must support that the patient's condition required immediate medical attention and that any delay in treatment would have posed a significant risk to the patient's health or well-being.
The physician is responsible for providing appropriate emergency or urgent care to the patient, stabilizing the condition, and ensuring proper documentation of the medical necessity for the services provided. The physician must also adhere to Medicare's billing guidelines for opt-out providers.
In simple words: If you're a Medicare patient and need emergency care from a doctor who doesn't normally accept Medicare, they will use this code so Medicare can help cover the cost.
Modifier GJ indicates a service provided by a physician who has opted out of Medicare, but is rendering emergency treatment to a Medicare beneficiary.The physician does not have a private contract with the patient for services and must submit the claim to Medicare on the patient's behalf. The physician cannot bill the patient more than Medicare's limiting charge.For unassigned claims, Medicare reimburses the patient directly.To submit an assigned claim, the provider can complete a CMS-855 enrollment form without impacting their opt-out status for other services. The medical record must clearly document the emergency or urgent nature of the services provided.
Example 1: A Medicare patient experiences a sudden onset of severe chest pain while traveling and seeks treatment at the nearest emergency room. The physician on duty has opted out of Medicare but provides emergency care to stabilize the patient. Modifier GJ is appended to the appropriate procedure codes to indicate the circumstances of the service., An opt-out physician is called to the scene of a car accident involving a Medicare beneficiary.The physician provides urgent care at the roadside before the patient is transported to the hospital. The physician uses modifier GJ when billing Medicare for the services provided., A Medicare patient experiences a serious allergic reaction at home. An opt-out physician who lives nearby responds to the emergency and provides urgent care to stabilize the patient's condition before an ambulance arrives. The physician appends modifier GJ to the codes billed to Medicare.
Documentation must support the medical necessity of the emergency or urgent service provided. It should include details about the patient's presenting condition, the services rendered, and the rationale for the services being considered emergent or urgent.
** If follow-up care is required and is not related to the initial emergency, the physician must obtain a private contract with the patient to bill for those services, as Medicare will not cover non-emergency care from an opt-out provider.If the follow-up care is directly related to the original emergency, Medicare will continue to pay until the patient no longer requires such care.
- Payment Status: Active
- Specialties:Emergency Medicine, potentially any specialty depending upon the nature of the emergency.
- Place of Service:Emergency Room - Hospital,Office, Home,Ambulance - Land, Independent Clinic,Other Place of Service (depending on where the emergency occurs)