Sunday, December 1, 2013

Medicare update on ABN and GA modifiers

ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary , the
provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and  necessary) with the service or item.

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in  the provider having to assume financial responsibility for the denied service or item.
Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier  GZ is billed, the provider assumes financial responsibility if the service or item is denied.

Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

GA modifier and appeals
When a patient is notified in advance that a service or item may be denied as not medically necessary , the provider must annotate this information on the claim (for both paper and electronic claims) by reporting the modifier GA (waiver of liability statement on file).

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in  the provider having to assume financial responsibility for the denied service or item.
Nonassigned claims containing the modifier GA in which the patient has been found liable must have the patient’s written consent for an appeal. Refer to the Contact Information section of this publication for the address in which to send written appeals requests.

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