Many rural hospitals don’t have access to proper physicians, or the access is limited. That’s why they often rely on non-physician practitioners (NPPs) to deliver care. Nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) are often the primary point of contact for patients, especially in Critical Access Hospitals (CAHs). However, billing the services of these NPPs is different from regular billing.
Their billing is based on different rules. One such rule is appending the GF modifier to claims. Getting it wrong, or omitting it entirely, can lead to overpayments and denials. That’s why we have created this detailed guide. We will explain what modifier GF is, when it is used, and some essential billing guidelines. So, let’s start.
GF Modifier – Description
The GF modifier is defined as:
Non-physician (e.g., nurse practitioner (NP), certified registered nurse anesthetist (CRNA), certified registered nurse (CRN), clinical nurse specialist (CNS), physician assistant (PA)) services in a critical access hospital.
That is the official definition, but let’s break it down in more detail to understand what it means.
GF modifier is an HCPCS Level II modifier. It is used only for the billing of Method II Critical Access Hospitals. As the definition explains, it is used to identify that a service in the CAH was performed by a non-physician practitioner, rather than a physician. If you don’t append this modifier, the payers will assume that the service was rendered by a physician. That assumption, when incorrect, results in an overpayment that puts the CAH at audit risk.
However, an important point to note here is that the official definition is a bit misleading. Even though the definition mentions certified registered nurse anesthetist (CRNA), CMS guidelines specifically mention that GF should not be used for CRNA services.
Scenarios Where the GF Modifier is Applicable
Here are a couple of real-world scenarios to show you how this modifier is used practically:
Nurse Practitioner Managing a Chronic Condition
Suppose a patient has type 2 diabetes. He comes to the outpatient clinic of a rural CAH. This is his follow-up checkup. The CAH has elected Method II, and all practitioners have reassigned their billing rights to the hospital. So, during the checkup, a nurse practitioner conducts the evaluation, reviews recent lab work, adjusts the patient’s medication regimen, and documents a detailed clinical note.
Since the evaluation was performed by a nurse practitioner in a CAH, the billing department should append the GF modifier to the claim along with the appropriate CPT code.
Physician Assistant Providing Wound Care
Suppose a patient presents to a CAH’s outpatient department for wound care. The wound was created after a minor surgical procedure. The CAH’s physician assistant evaluates the wound, applies appropriate dressings, and documents the service.
Like the first scenario, the GF modifier is appended to the procedure code to indicate that the service was rendered by a PA, not a physician, in a CAH that has elected the Method II billing option.
GF Modifier – Billing Guidelines
Using modifier GF correctly requires more than knowing the definition. The following are some additional guidelines that you should consider while filing claims:
- The GF modifier only applies to Critical Access Hospitals that have opted for Method II payments.
- Method II professional services must be billed on the UB-04 institutional claim form using revenue codes in the 096X-098X series. Submitting on CMS-1500 will result in denials.
- The rendering non-physician practitioner must be Medicare-enrolled and have formally reassigned billing rights to the CAH.
- When the rendering provider differs from the attending provider, their NPI must be listed at the claim line level.
- Medical records must identify the practitioner’s name, credentials, and scope of practice.
Wrapping Up
Let’s wrap up this guide. We hope that with the help of this guide, you will be able to use the GF modifier correctly. In case you missed anything, here is a quick recap of the important points:
- Modifier GF is used to bill the services of non-physician practitioners in CAHs.
- GF must be appended to the procedure code on the UB-04 claim form.
- The modifier does not apply to CRNA services and does not belong on CMS-1500 claims.
Insurance billing for Critical Access Hospitals can be complex. Also, it can be hard to find experienced billers in rural areas. That’s why it is better to outsource medical billing services to specialized billing companies like MediBillMD. Partnering with professionals will help you achieve a quicker turnaround time and better revenue collection.
