Reason Code 4
Medicare Remarks: “The procedure code is inconsistent with the modifier used or a required modifier is missing.”
The most common reason for this denial is a missing professional discipline modifier.
| GP Modifier | Physical Therapy |
| GO Modifier | Occupational Therapy |
| GN Modifier | Speech-Language Pathology |
Claim Corrections
Option 1: Log into your MAC portal and reopen the claim. Add the appropriate professional discipline modifier and reprocess the claim.
Option 2: If you do not have a MAC portal login then add the appropriate professional discipline modifier to your patient accounting software and resubmit the claim.
* NOTE: The following remark codes (MA 130 and MA 59) will accompany reason code 4 but do not provide any additional information. Once you fix the missing professional modifier the following two codes will resolve as well.
Reason Code MA 130
“Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit the correct information to the appropriate fiscal intermediary or carrier.” Link
Reason Code MA 59
“The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.” Link
Related Denials and Rejections
Where Does the Professional Discipline Modifier Go on the Physical Therapy Claim?
Every software is a little different, but the professional modifier GP would go in box 24D to the right of the CPT code. You would add a GP modifier on every line item.
See image below for example:
United Healthcare Requires 59 Modifier for CPT Code 97530 and CPT Code 97140 Combo
News 2022: Unitedhealthcare Requires 59 Modifier for Therapy Services Despite the recent changes to the NCCI edits no longer requiring CPT Code 97530 to require a 59 modifier when billed on the same date of service and by the same therapist as CPT Code 97140 some...
Physical Therapy Business Checks for Medicare PECOS
It may seem a little crazy, but YES, in 2022 Medicare still expects new business owners to have paper business checks. If you are submitting your Medicare provider enrollment via PECOS you are asked to either upload a copy of a voided business check or a letter from...
