NARHC Forum

Contributor: Joyce Harper, MDH Family Medicine

Could someone please tell me on the list of Qualifying visit list do I need to add the CG modifier to these codes? I have been getting some conflicting answers.

Contributor: Nathan Baugh, National Association of Rural Health Clinics

Modifier CG should be used to indicate which service met the definition of a RHC encounter. 

The qualifying visit list has been confusing our community for years now. It really does not serve a purpose and I have asked CMS to remove all references to it. 

This confusion is further compounded by the "Conflict Add-On" list which causes claims to reject if certain CPT codes are billed with modifier CG. There are some codes on the Conflict Add-On list which, by all accounts, should be considered valid RHC encounters and I have asked CMS to remove those codes from the Conflict Add-On list. I am hopeful that the quarterly update in April will do that. 

For additional context, the qualifying visit list or QVL was created when RHCs first began reporting CPT codes back in 2016. The initial list was quite small and we protested the number of codes on the list saying that many other services qualified as RHC encounters. CMS then agreed to expand the list considerably and asked us for a list of codes that we want on the list. The RHC community offered up hundreds of codes and CMS realized that instead of maintaining a qualifying visit list that they would have to constantly update, they should instead simply create a policy wherein modifier CG allows the RHC to indicate that the service met the definition of a RHC encounter. 

If you look at the document that contains the QVL you will see this key sentence, and I quote:

For dates of service on or after October 1, 2016, a medically-necessary service not on the current QVL can be billed as a stand-alone billable visit if the service meets Medicare coverage requirements, is within the scope of the RHC benefit, and is not furnished incident to a physician’s service.

Therefore, the QVL does not matter. However, many MACs, and written policies still reference "qualifying visits" and it confuses folks, we will push CMS, the MACs, and others to remove this confusing language.

Modifier CG is properly used by RHCs to 1-indicate which service was the primary reason for the medically necessary face-to-face visit that met the definition of an RHC encounter; and 2-to indicate which line on the RHC claim contains the bundled charges for all services subject to coinsurance and deductible.

There are some CG nuances in regards to preventive services and modifier 25/59 but this is already long so I won't get into that. 

I hope this is helpful context, we will work with CMS to try to improve the clarity of official communications regarding this policy.  

Contributor: Joyce Harper, MDH Family Medicine

Contributor: Jeana Murphy, CCMH Medical Mall Clinic

So when billing these codes on the RHC Modifier HCPCS Conflict   Add On List  alone without the CG modifier to WPS Medicare - we get the code : CO 97  The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudication.

Since the end policy that CMS determined that these service do not meet the definition of a RHC encounter and wouldn't be a part of our AIR  ,

Then is this going to be a contractual adjustment that would go on cost report or a write off as not covered?

 And - it states under CO- Contractual Obligations on the Medicare EOB:. The patient may not be billed for this amount.  

I tried finding this information on the CMS website

Jeana Murphy

RHC Biller

CCMH Medical Mall Clinic

1317 S Hwy 32

El Dorado Springs, MO 64744

P-  417-876-3592

F-  417-876-2818