Medicare Compliance & Reimbursement

One of the obstacles associated with submitting advance beneficiary notices (ABNs) to Medicare is attaching the G modifier that matches the case specifics.

Why? You have a choice of four G modifiers to use with your claims, depending on the payment situation, that explain to your insurer whether an ABN is on file, and if so, why.

“CMS has provided communications regarding the use of G modifiers. These modifiers are recommended to be used to help ensure the proper processing of the claim,” explains Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, of ClaimDOC in Des Moines, Iowa. “The G modifiers additionally allow Medicare to provide the applicable Medicare remittance advice notice comments and corresponding patient financial responsibility or provider responsibility information.”

Append the appropriate G modifier, as follows, to give the payer more information:

• GA (Waiver of liability statement issued as required by payer policy, individual case): When the ABN is signed, you should submit the service with a GA modifier, which tells your Medicare carrier that you have a properly executed ABN on file.
• GX (Notice of liability issued, voluntary under payer policy): Use modifier GX in any case where a provider issues a voluntary ABN for a service that Medicare does not cover.
• GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit): Use modifier GY to explain that Medicare statutorily excluded the item or service, or that it doesn’t meet the definition of a Medicare benefit. And append GY when you are not expecting payment — despite the fact that you are submitting the claim for this line item anyway.
• GZ (Item or service expected to be denied as not reasonable and necessary): If the provider believes the payer will deny a service for lack of medical necessity — or fails to have the beneficiary sign the ABN — you will apply modifier GZ.