[Federal Register Volume 73, Number 71 (Friday, April 11, 2008)]
[Notices]
[Pages 19940-19941]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-7642]


-----------------------------------------------------------------------

DEPARTMENT OF VETERANS AFFAIRS


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, (202) 254-0384. (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

[[Page 19941]]

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.
 [FR Doc. E8-7642 Filed 4-10-08; 8:45 am]
BILLING CODE 8320-01-P