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:
Do you need to become a physical therapist to deliver the value of a physical therapist?
Do you need to become a physical therapist to deliver the value of a physical therapist?
Comparing Reimbursement for 3 Different Medicare Advantage Plans – $FREE
How can you decide to join a payer network when you have no idea what the contract will pay or what your obligations will be?
In this 18:32 video I review three different Medicare Advantage plan reimbursements from a 2019 fee schedule along with sharing some tips and bonus information that may help you know what to look for when deciding to join a payer network.
