ED Coding and Reimbursement Alert

CMS will delete HCPCS modifier -GX (service not covered by Medicare) as of Jan. 1, 2002. This modifier has allowed physicians to bill Medicare for noncovered services in order to get a denial, after which the physician can submit the charges to a secondary payer. When the modifier was reported, Medicare understood that physicians were not trying to beat the system and obtain inappropriate reimbursement. Instead, it signaled that they knew it wasnt covered and needed an explanation of medical benefits (EOMB) to confirm the denial.
 
Two modifiers will take the place of -GX, which was used in many situations. The new modifiers more clearly define the reasons for denial. Modifier -GY will describe an item or service statutorily noncovered, while -GZ will describe an item or service not reasonable and necessary.
 
Modifier -GY should be assigned for services that Medicare, by law, cant pay for. These services are assigned a status code of N in the Medicare fee schedule and include many screening evaluations such as routine chest x-rays. On the other hand, coders would append modifier -GZ when national or local Medicare policy has excluded specific services as not reasonable or necessary and the emergency physician could not obtain an advanced beneficiary notification (ABN) because of EMTALA rules.
 
With its implementation of -GY and -GZ, Medicare has also added two Q codes:

Q3015 item or service statutorily noncovered, including benefit category exclusion (used only when no specific code available)

Q3016 item or service not reasonable and necessary (used only when no specific code available).

 
These codes would be assigned when no CPT or HCPCS code is available to describe the services rendered for example, when the noncovered or not medically indicated service is represented by an unlisted-procedure code (xxx99 codes). Additional information on these new modifiers may be found in Program Memorandum B-01-58, available on the CMS Web site www.hcfa.gov/pubforms/transmit/B0158.pdf.