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Cardiology Coding Alert

Cardiologists Must Determine Which Procedures Are Reasonable

Published on Sun Jul 01, 2001

The Centers for Medicare & Medicaid Services (CMS, formerly HCFA) has deleted modifier -GX (service not covered by modifier) and replaced it with two new modifiers, one of which makes cardiologists responsible for deciding which of the procedures they perform are reasonable and necessary.

Two new codes -- Q3015 (item or service statutorily noncovered, including benefit category exclusion [use only when no specific code is available]) and Q3016 (item or service not reasonable and necessary [use only when no specific code is available]) -- have also been added to HCPCS.

According to an April 26 Medicare transmittal (B-01-30), modifier -GX has been replaced by modifiers -GY (item or service statutorily noncovered) and -GZ (item or service not reasonable and necessary).

Modifier -GY and code Q3015 perform the same function as did modifier -GX, which was used to obtain a denial for a noncovered service so that a third-party carrier or the patient could be billed.

Modifier -GZ and code Q3016, however, appear to force the physician to determine that a procedure he or she considers medically necessary is not considered reasonable and necessary by CMS. The memorandum states, The new modifiers, -GY and -GZ, must be used when a specific code is available but the provider or supplier wants to indicate that the item or service is not covered or is not reasonable and necessary [emphasis added].

The transmittal elaborates:

Medicare may cover certain items and services as reasonable and necessary under certain circumstances. These same items and services may not be covered benefits under other circumstances. When a provider or supplier furnishes either an assigned or unassigned service or item that they believe is not reasonable or necessary according to Medicare policies and regulations, the specific HCPCS code that describes the service or item furnished must be submitted along with the -GZ modifier. If there is no specific code available, the provider or supplier may submit the claim using the Q3016 code. Claims submitted using the -GZ modifier or the Q3016 code may not be auto-denied simply based on the code. However, the carrier may auto-deny based on other criteria such as diagnosis to procedure coding. These claims should be included in regular medical review procedures.

Use Modifiers -GZ and -GA Together

The memorandum also states, When a service is performed or item supplied that is not reasonable and necessary under the specific circumstances, it is the responsibility of the provider or supplier to notify the beneficiary in writing through the use of the advance beneficiary notice (ABN). Under these circumstances, the provider or supplier is instructed to file the services or items with the -GA modifier (waiver of liability statement on file) and Q3016 or modifier -GZ, not instead or in place of them.

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