Do you know that Medicare will not pay for any medical items or services that are provided to a patient who is incarcerated? This applies even if the patient is a Medicare beneficiary. However, there is an exception that can bypass this rule.
When a state or local jurisdiction meets specific legal conditions, Medicare can pay for the services, but only if they append the correct modifier to the claim. That is the QJ modifier.
In this guide, our billing experts at NeuraBill have tried to explain what this modifier means and how you can use it correctly in your claims. So, let’s start.
QJ Modifier – Description
The QJ modifier is defined as:
“Services/items provided to a prisoner or patient in state or local custody; however, the State or local government, as applicable, meets the requirements in 42 CFR 411.4(b).”
Medicare has a rule that sits under 42 CFR 411.4(a). This rule basically restricts Medicare from paying for any person who has no legal obligation to pay for it, and no other insurer or party is obligated to pay either. This rule specifically applies to incarcerated individuals. So, in simple terms, Medicare does not pay for people who are considered incarcerated under Medicare’s rules.
However, there is an exception in the same rule book that allows Medicare to pay for these individuals under some very strict requirements. When these requirements are met, the QJ modifier is used in the claims. This modifier tells Medicare that the requirements for the exception rules are met, and the payer can process it.
To use this code correctly, you need to understand who is considered a patient in custody. The table below shows who is considered in custody and who is not. Please note that all these categories are per the January 1, 2025 update:
| Considered in Custody | Not Considered in Custody |
|---|---|
| Incarcerated in a jail, prison, penitentiary, or similar institution. | Released to the community pending trial, including those on bail. |
| On medical furlough or a similar temporary arrangement. | On parole. |
| Escaped from confinement by a penal authority. | On probation. |
| Required by criminal law to live in a mental health facility. | On home detention or living in a halfway house or similar transitional facility. |
Source: CMS
We have already mentioned above that there are strict rules that govern the exception criteria and the use of the QJ modifier. The following are the three rules. Take a look:
- State or local law requires the individual to repay the cost of items and services received while in custody.
- The penal authority enforces this requirement by billing every individual in custody, regardless of whether they carry Medicare or other health insurance.
- The penal authority pursues collection of these amounts with the same effort and methods it uses for any other outstanding debt, including filing liens against assets or income from outside the facility.
With that said, please note that it is important that all three of these conditions are fulfilled. If even one of these is not met, you cannot use QJ.
Appropriate Use Cases for QJ Modifier
The description can be a little confusing. To clarify, let’s look at a couple of real-world scenarios in which the QJ modifier can be used:
Chronic Condition Management in a State Correctional Facility
Suppose a patient is being held legally in a state correctional facility. While in custody, the patient is diagnosed with type 2 diabetes. The facility has a contracted physician who provides all the ongoing management services, including office visits and lab work. So, the same physician checks the incarcerated patient we are discussing.
The essential point to note about the facility is that it operates in a state that has a policy that all inmates have to pay for their medical costs. Due to this, the facility routinely pursues collection from all inmates.
Now, since all the conditions that we discussed in the previous section are fulfilled, the billing team can bill the services of the physician by appending the QJ modifier to the diabetes management service code.
Emergency Care During Medical Furlough
Let’s consider another scenario. A patient held in county jail custody is granted a temporary medical furlough to receive treatment at an outside hospital for a worsening cardiac condition. The hospital provides diagnostic testing and admits the patient briefly for observation. The county has an established billing and collection policy for medical costs incurred by individuals while in custody, and it applies this policy uniformly.
Because the patient remains in custody status during the furlough and the county meets the repayment and collection requirements, the hospital’s outpatient claims for this encounter should carry the QJ modifier on each applicable line.
Accurate Usage Guidelines for QJ Modifier
Here are some additional guidelines about the QJ modifier that will help you avoid claim denials:
Patient Status
The claim with modifier QJ must be submitted for a patient in state or local government custody and who is an active Medicare beneficiary.
Claim Type and Modifier Placement
- For outpatient claims: Add the QJ modifier to any line item where the date of service falls during the incarceration period. This applies to Part B claims handled by A/B MACs and to DME MACs.
- For inpatient claims: Don’t use QJ. Instead, from July 1, 2025 onward, hospitals should use condition code 63 to show that the incarceration-period services meet the requirements under 42 CFR 411.4(b).
- If an inpatient stay only partly overlaps with the incarceration period, split the billing: The overlapping days, services, and charges go in as non-covered, while the rest of the stay is billed normally as payable.
Documentation Requirements
- Keep records showing the patient’s custody status.
- Document the exact dates of custody.
- Include proof that the responsible government entity actually enforces its repayment requirement. This could be the jurisdiction’s billing and collection rules, manual instructions, or directives.
Final Thoughts on QJ Modifier
We have reached the end of our guide. Although not very common, the QJ modifier is one of the most important modifiers in medical billing. Before concluding, here’s a quick summary of the important points that we discussed:
- QJ is used to bill for the services and items that are provided to an incarcerated patient.
- However, for its use, the holding facility must meet the three requirements that we discussed in the description section.
- Provide detailed documentation with the claims that confirm the incarceration period of the patient.
If your practice or facility handles claims for patients in custody, precision matters. In-house billing teams can struggle with these types of claims. So, it is better to get professional medical billing and coding services from renowned companies like NeuraBill.
