The Veteran's Choice Program & Your Claims
Q: I have recently begun treating veterans under the Veteran's Choice program. I am getting paid just fine for acupuncture codes and evaluation and management services but have been denied all physical medicine codes including infra-red heat 97026, massage 97124 and manual therapy 97140. I have never needed a modifier on these codes for payment from insurance but the denial from the VA states that I am missing a modifier. I called and they would not tell me what modifier is needed. Can you help?
Indeed, the Veterans Administration is paying directly to acupuncture care under the VA Choice or PC3 Program. There are currently two administrators for this program Health Net for the Northeast and Triwest for the Southwest (approximate geographic regions). Treatment, as you have realized, must be authorized but does indeed pay for exams, acupuncture and physical therapies.
The VA Program
The authorization for acupuncture care is typically 12 visits and includes an exam, acupuncture, and physical medicine services specifically infra-red heat, massage and manual therapy. The authorization will typically list the authorized or allowed services, and if you wish to go beyond any services not listed those must be authorized as well. I have seen authorizations as much as 52 for a 12 month period, this is not a typo, yes 52 for a year. Clearly a severe and chronic patient.
Once you have been authorized, billing is sent to the carrier on a standard 1500 claim form. Acupuncture coding does not need any modifier, however, evaluation and management (E&M) coding, whether new or established patient codes must also be appended with modifier 25 when treatment and E&M are provided on the same date. This is not unusual and now all claims with treatment and E&M are coded for acupuncture claims.
Physical medicine codes when billed by an acupuncture professional requires no modifiers in most instances and hence your inquiry as to what they are asking for. The VA is considered a federal payer and under federal guidelines (like Medicare) their special modifiers are utilized for physical medicine services. Of course, why would an average acupuncturist know about Medicare rules when Medicare has no acupuncture benefits.
The New Modifier
The missing modifier needed for physical medicine services is modifier GP. The GP modifier is to indicate that the services were delivered under an outpatient therapy plan of care. Essentially all Federal claims will use this including the VA. Without this modifier, the physical medicine services will be denied.
Therefore when billing a VA claim under VA Choice include all PT codes modifier GP in addition to any other modifier required. The order of the modifiers are not important but simply that all modifiers appear. For instance, you can code 97026 GP. Most often for acupuncture, only the one modifier is needed but if you ever receive a denial for a therapy being inclusive to another service billed the same date you also want to use modifier 59 to designate that the services were separate and distinct.
For instance, if you were denied for manual therapy 97140 as being inclusive to other services billed the day you would also need to include this 59 modifier and for VA would mean the use of 2 modifiers both GP and 59. The order of modifiers does not matter but simply that they both appear.
In conclusion, the simple answer is to use modifier GP on all physical medicine services billed under the VA Choice plan.