Beginning on October 1, 2016, Rural Health Clinics (RHCs) shall report modifier CG (policy criteria applied) on RHC claims and claim adjustments. You should report modifier CG on one line with a medical and/or a mental health Healthcare Common Procedure Coding System (HCPCS) code that represents the primary reason for the medically necessary face-to-face visit. This line should have the bundled charges for all services subject to coinsurance and deductible. If only preventive services are furnished during the visit, report modifier CG with the preventive service HCPCS code that represents the primary reason for the medically necessary face-to-face visit.
Medical and preventive services HCPCS codes are billed with revenue code 052X
Mental health services HCPCS codes are billed with revenue code 0900
As part of this change, we have identified claims submitted without modifier CG that resulted in a zero dollar payment amount. Effective immediately, we will return (TB9997) claims missing the CG modifier and request that you verify your billing and correct/resubmit as appropriate. For claims that previously processed with a zero dollar payment amount, please submit claim adjustments with the appropriate modifier.
For additional details, please review the following: