E8-7642. GR Modifier Use by the Department of Veterans Affairs

AGENCY:

Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

The Department of Veterans Affairs (VA) bills health benefit plans for the cost of certain care delivered to veterans. Starting with dates of service on and after January 1, 2006, when medical residents deliver care in a VA Medical Center or clinic under the supervision of an attending physician, VA will issue its bill in the name of the attending physician but append the Healthcare Common Procedural Coding System (HCPCS) Level II modifier “-GR” to the CPT code for the service. For billing and payment purposes, the “-GR” modifier when used on VA billings has the same effect as the “-GC” or “-GE” modifier when used in billings from non-VA providers. The use of the “-GC” “-GE” modifiers is generally discontinued in VA billings; they are used only as specifically permitted by VA policy.

FOR FURTHER INFORMATION CONTACT:

Tony A. Guagliardo, Director, Business Policy, Chief Business Office (163), Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, [phone]. (This is not a toll free number).

SUPPLEMENTARY INFORMATION:

The Veterans Health Administration (VHA) supports the Nation's largest graduate medical training program; each year approximately 30 percent of all the medical residents in the United States receive some or all of their training in a VHA Medical Center or clinic. VA policy is that the cost of clinical services provided by medical residents will be billed to third party health benefit plans as provided in 38 U.S.C. 1729 when the resident is supervised by an attending physician in accordance with VHA policy.

For coding and billing purposes, documentation of resident supervision is different in VHA Medical Centers or clinics than in the non-VA sector. VHA requires that any services provided in whole or in part by a resident must be notated with the designation “-GR”. In the non-VA sector, services provided in whole or in part by a resident must be notated with either the “-GC” or “-GE” modifier as appropriate. The Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) has adopted billing rules which generally require the documentation of the physical presence of a supervising attending physician for resident-delivered services to be eligible for payment under the Medicare or Medicaid program. As a result, non-VA sector graduate medical education programs are generally structured to take advantage of CMS-based payments.

When billings for resident-delivered services are issued in the non-VA sector, a Health Care Procedural Coding System (HCPCS) Level II modifier, “-GC” can be appended to the Common Procedural Terminology -4 (CPT-4) service code to show that the physical-presence billing requirement was met. In limited circumstances where the CMS billing rules do not require physical-presence supervision, the HCPCS modifier “-GE” can be used. In each case, billings in the non-VA sector are issued in the name of the attending physician.

These CMS billing rules have their foundation in technical aspects of HHS's funding of graduate medical education (GME) programs which do not apply to VA, for the simple reason that HHS does not fund VA GME programs. Additionally, VA does not bill Medicare or Medicaid for services provided to veterans.

VHA resident supervision policy is based on the standards of the Accreditation Council for Graduate Medical Education (ACGME) which provide that residents should be appropriately supervised in the context of progressively increasing responsibility, and that training programs must identify the decision-making which allocates responsibility to individual residents. VHA's resident supervision policy is set forth in its Handbook 1400.1, which may be found at http://www1.va.gov/​vhapublications/​ViewPublication.asp?​pub_​ID=​1289. This policy is consistent with ACGME standards and quality of care, patient safety, and resident education objectives.

To facilitate billing of VA-delivered resident services, VHA requested and CMS authorized the use of a VA-specific HCPCS II modifier, “-GR.” When appended to a CPT-4 code, the “-GR” modifier means:

“These services were provided in whole or in part by a resident at a VA Medical Center or clinic, supervised in accordance with VA policy.”

For billing and payment purposes, when used on a billing from a VA Medical Center or clinic, the “-GR” modifier has the same effect as the “-GC” or “-GE” modifier when used by the non-VA sector. VA practice, consistent with that of the non-VA sector, is to issue billings in the name of the attending physician.

Please note that when veterans receive VA-funded care in a non-VA medical facility, clinic, or office, VHA policy does permit the use of the “-GC” and “-GE” modifiers on billings if the modifiers are otherwise appropriate.

Approved: April 4, 2008.

Gordon H. Mansfield,

Deputy Secretary of Veterans Affairs.