Showing posts with label GA. Show all posts
Showing posts with label GA. 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

Friday, July 9, 2010

Advance beneficiary notice modifiers GZ,GA

Advance beneficiary notice

• Modifier GZ must be used when providers, 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 benefi ciary notifi cation (ABN) signed by the benefi ciary.

Modifier GA must be used when providers, physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on fi le an ABN signed by the beneficiary.

• All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with modifi er GA or GZ.

How to use ABN Modifiers?

Modifiers GA and GX were created to differentiate between mandatory and voluntary ABNs. Modifier GA has been redefined as “waiver of liability statement issued as required by payer policy” and should be used when a mandatory ABN was issued to a beneficiary. Billing staff should not report Modifier GA with any other liability-related modifier such as GZ (item or service expected to be denied as not reasonable and necessary); EY (no doctor’s order on file); GL (medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN); GX (notice of liability issued, voluntary under payer



Although, it is voluntary to provide an ABN for items or services that are statutorily excluded or lack a Medicare benefit category, a facility’s conditions of participation may require the provider to inform the beneficiary of non-coverage.



Moda Health Commercial plans:

Modifiers GA, GX, GY, and GZ are considered valid for commercial lines of business. We are prepared to process Medicare supplement claims that may have been submitted to Original Medicare with these modifiers.

In addition, non-covered screening procedure codes submitted with a screening diagnosis code and modifier GA or GX appended will deny to member liability. Modifiers GY and GZ have no effect on this process. Please refer to Moda Health Reimbursement Policy # RPM037 “Preventive Services versus Diagnostic and/or Medical Services” for complete information.

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