Showing posts with label ABN modifier. Show all posts
Showing posts with label ABN modifier. Show all posts

Sunday, October 2, 2016

Usage of Modifier GA , GK, GL , GY AND GZ



GA  Waiver of Liability Statement Issued, as Required by Payer Policy

ABN required; beneficiary liable
To signify a line item is linked to the mandatory use of an ABN when charges both related to and not related to an ABN must be submitted on the same claim
Line item must be submitted as covered; Medicare makes a determination for payment


GK  Reasonable and Necessary Item/Service Associated with a –GA or –GZ modifier


ABN required if –GA is used; no liability assumption since this modifier should not be used on institutional claims
Not used on institutional claims. Use –GA or –GZ modifier as appropriate instead
Institutional claims submitted using this modifier are returned to the provider



GL Medically Unnecessary Upgrade Provided instead of Non-Upgraded Item, No Charge, No ABN

Can’t be used if ABN/HHABN is required, COPs may require notice, recommend documenting records; beneficiary liable
Use only with durable medical equipment (DME) items billed on home health claims (TOBs: 32x, 33x, 34x)
Lines submitted as non-covered and will be denied
GY  Modifier -  Item or Service Statutorily Excluded or Does Not Meet the Definition of Any Medicare Benefit

Non-covered by Medicare Statute (ex., service not part of recognized Medicare benefit)
Optional notice only, unless required by COPs; beneficiary liable
Use on all types of line items on provider claims. May be used in association with modifier –GX.
Lines submitted as non-covered and will be denied

GZ  Item or Service Expected to Be Denied as Not Reasonable and Necessary

May be non-covered by Medicare
Cannot be used when ABN or HHABN is actually given, recommend documenting records; provider liable
Available for optional use on demand bills NOT related to an ABN by providers who want to acknowledge they didn’t provided an ABN for a specific line
Lines submitted as non-covered and will be denied

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.

Saturday, May 29, 2010

Medicare ABN Modifier

ABN Modifiers

Modifier GA should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as reasonable and necessary and they have on file an Advance Beneficiary Notification (ABN) signed by the beneficiary. Modifier GY should be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered, or is not a Medicare benefit.

Modifier GZ should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notice (ABN) signed by the beneficiary.

Most read cpt modifiers