Modifier GJ- Opt-Out Practitioner Emergency or Urgent Service

Modifier GJ identifies emergency or urgent services furnished by an opt-out physician or practitioner to a Medicare beneficiary without a private contract.

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What is Modifier GJ?

Modifier GJ is used when an opt-out physician or practitioner furnishes emergency or urgent care to a Medicare beneficiary who has not entered into a private contract with that practitioner.

Physicians and practitioners who opt out of Medicare generally furnish covered services to Medicare beneficiaries through private contracts rather than submitting claims to Medicare. Emergency and urgent care situations are an important exception.

When an opt-out physician or practitioner provides emergency or urgent care to a beneficiary with whom they do not have a private contract, CMS requires the practitioner to submit the applicable Medicare claim with Modifier GJ.

GJ communicates the special opt-out circumstances surrounding the service. It does not automatically establish coverage or payment for the underlying service.

When to Use Modifier GJ

Opt-Out Practitioner: The physician or practitioner has properly opted out of Medicare.

Emergency or Urgent Care: The beneficiary requires an emergency or urgent service.

No Private Contract Exists: The beneficiary has not previously entered into an applicable private contract with the opt-out practitioner.

Medicare Claim Is Required: The practitioner submits the emergency or urgent service to Medicare under the applicable opt-out rules.

Eligible Service Is Reported: The CPT or HCPCS code accurately represents the service actually furnished.

When NOT to Use Modifier GJ

Practitioner Has Not Opted Out: GJ is specifically associated with services furnished by Medicare opt-out physicians or practitioners.

Routine Non-Urgent Care: Do not use GJ for ordinary scheduled services simply because the practitioner has opted out.

Private Contract Already Applies: Medicare generally cannot pay for emergency or urgent services when the beneficiary and opt-out practitioner previously entered into an applicable private contract during the opt-out period.

Emergency or Urgent Condition Has Ended: Routine follow-up care after the beneficiary no longer requires emergency or urgent care does not automatically qualify for GJ.

To Obtain Medicare Payment: GJ should only be reported when the actual circumstances satisfy Medicare's opt-out emergency or urgent care requirements.

Billing Example

An opt-out physician encounters a Medicare beneficiary who requires urgent treatment for a fractured leg.

The beneficiary does not have an existing private contract with the physician.

The physician provides the medically necessary urgent treatment and submits the applicable service to Medicare with Modifier GJ.

CMS uses GJ to identify that the service was furnished by an opt-out practitioner under the emergency or urgent care exception. CMS specifically uses a fractured leg as an example of circumstances in which these requirements can apply.

Documentation Requirements

Emergency or Urgent Condition: Document the condition requiring immediate or urgent treatment.

Opt-Out Status: The practitioner should have valid Medicare opt-out status for the applicable period.

No Applicable Private Contract: Records should support the billing circumstances involving the beneficiary and practitioner.

Service Performed: Documentation should support the CPT or HCPCS code reported.

Medical Necessity: The medical record should establish why the emergency or urgent service was reasonable and necessary.

Follow-Up Status: When continued treatment occurs, documentation should establish whether the beneficiary still requires emergency or urgent care.

Billing and Claim Considerations

Modifier GJ represents a specific exception to Medicare's normal opt-out rules.

CMS states that when an opt-out practitioner furnishes emergency or urgent care to a Medicare beneficiary without an applicable private contract, the service is not excluded from Medicare coverage merely because the practitioner has opted out. The practitioner must submit the claim with the appropriate HCPCS code and GJ.

Medicare's ordinary rules governing the service can then apply, including applicable assignment and limiting-charge requirements.

The distinction between urgent treatment and later routine follow-up care is particularly important. CMS explains that once the beneficiary no longer needs emergency or urgent care, subsequent non-urgent treatment does not continue qualifying under the emergency exception simply because the original service did.

Providers should therefore evaluate each subsequent service based on the beneficiary's condition and applicable opt-out requirements.

Common Billing Mistakes

Using GJ for Any Opt-Out Service: GJ specifically applies to qualifying emergency or urgent services.

Using GJ for Routine Follow-Up: Once emergency or urgent circumstances end, ordinary opt-out and private-contract requirements apply.

Ignoring an Existing Private Contract: A previously established applicable private contract can change how Medicare treats the service.

Using GJ for a Practitioner Who Has Not Opted Out: The modifier communicates the practitioner's Medicare opt-out circumstances.

Failing to Submit the Medicare Claim: CMS requires the opt-out practitioner to submit qualifying emergency or urgent services when GJ circumstances apply.

Assuming GJ Guarantees Payment: The underlying service must still satisfy applicable Medicare requirements.

Common Denial Reasons

GJ Is Missing: CMS states that the Medicare contractor must deny the claim when the required GJ modifier is not submitted in applicable opt-out emergency or urgent care circumstances.

Service Is Not Emergency or Urgent: The circumstances do not qualify for the opt-out exception.

Private Contract Exists: An applicable private contract was already in effect between the beneficiary and practitioner.

Practitioner Status Is Incorrect: Claim information does not support the reported opt-out circumstances.

Underlying Service Is Unsupported: Documentation does not substantiate the CPT or HCPCS service reported.

Medical Necessity Is Unsupported: The medical record does not establish the need for the reported service.

Modifier GJ: Emergency Care vs. Routine Follow-Up

The key distinction for Modifier GJ is whether the Medicare beneficiary still requires emergency or urgent care.

An opt-out practitioner can furnish qualifying emergency or urgent treatment to a beneficiary without an applicable private contract and submit the service to Medicare using GJ.

Once the emergency or urgent condition has ended, however, routine follow-up services generally return to the normal Medicare opt-out rules.

CMS explains that an opt-out practitioner who asks the beneficiary to return for non-urgent follow-up generally must establish a private contract or refer the beneficiary to a Medicare physician or practitioner.

Frequently Asked Questions

Can an opt-out physician bill Medicare for emergency care?
Yes, under qualifying circumstances. When an opt-out physician or practitioner furnishes emergency or urgent care to a beneficiary without an applicable private contract, CMS requires submission of the service with Modifier GJ.

Can Modifier GJ be used for follow-up care?
Only while the beneficiary continues to require emergency or urgent care. Once care becomes routine or non-urgent, the normal opt-out and private-contract requirements apply.