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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say modifiers are used to identify therapy services whether or not financial 
limitations are in effect. When limitations are in effect, the CWF tracks the financial limitation based on 
the presence of therapy modifiers. 
Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of 
applicable therapy codes except as noted in Section 20 of this chapter. Consult Section 20 for the list of codes 
to which 
modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not 
qualified and recognized by Medicare to perform. The claim must include one of the following modifiers 
to distinguish the discipline of the plan of care under which the service is delivered: 
 
GN Services delivered under an outpatient speech-language pathology plan of care; GO Services 
 
delivered under an outpatient occupational therapy plan of care; or, GP Services delivered under an outpatient 
physical therapy plan of care. Contractors edit institutional claims to ensure the following: that a GN, GO or 
GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X. that no more than one GN, 
GO or GP modifier is reported on the same service line. that revenue codes and modifiers are reported only in 
the following combinations: 
Revenue code 42x (physical therapy) lines may only contain modifier GP Revenue code 43x (occupational 
therapy) lines may only contain modifier GO Revenue code 44x (speech-language pathology) lines may only 
contain modifier GN. You can find the guidance in the Medicare Claims Processing Manual, Chapter 5, 20.1 - 
Discipline Specific Outpatient Rehabilitation Modifiers  All Claims Medicare guidance says Providers should 
expect the following: 
MACs will return/reject claims which contain an "always therapy" procedure code, but do not also contain the 
appropriate discipline-specific therapy modifier of GN, GO, or GP. MACs will also return/reject claims if any 
service line on the claim contains more than one occurrence of GN, GO or GP therapy modifier. You can find 
the guidance in the MLN Matter MM10176.  
 
Medicare guidance says the A/B MACs (A) must provide a listing of the required data elements, including a 
brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the distinction 
between submissions which are not considered claims, but which are returned to provider (RTP) and 
submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted 
as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected 
on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected 
and re-submitted. 80.3.1 - Incomplete or Invalid Claims Processing Terminology The following definitions 
apply to 80.3.2. For carriers the requirements apply to Part B assigned and unassigned claims (Form CMS-
1500) or electronic data interchange equivalent. 
 Unprocessable Claim - Any claim with incomplete or missing, required information, or any claim that 
contains complete and necessary information; however, the information provided is invalid. Such information 
may either be required for all claims or required conditionally. 
 Incomplete Information - Missing, required or conditional information on a claim (e.g., no Unique Physician 
Identification Number (UPIN) / Provider Identification Number (PIN) or National Provider Identifier (NPI) 
when effective). 
 Invalid Information - Complete required or conditional information on a claim that is illogical, or incorrect 
(e.g., incorrect UPIN/PIN or NPI when effective), or no longer in effect (e.g., an expired number). 
 Required - Any data element that is needed in order to process a claim (e.g., Provider Name, Date of Service). 
A claim returned as unprocessable for incomplete or invalid information does not meet the criteria to be considered as a claim, is not denied, and, as such, is not afforded appeal rights.  You can find this information 
in the Medicare Claims Processing Manual Chapter 1 - General Billing Requirements 70.2.3.2 and 80.3.1. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.