Neurology & Pain Management Coding Alert

Question: Which modifier applies when the physician performed a noncovered service for a Medicare patient, but we didn't get an ABN?

New Jersey Subscriber

Answer: If the physician performed a non-covered service and there's no signed Advance Beneficiary Notice (ABN) on file, you should append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT® code describing the non-covered service. The advantage to reporting modifier GZ is avoiding the potential for fraud and abuse allegations. This modifier tells Medicare that you know you're submitting the code for a non-covered service, and you expect them not to pay for it.

Be forewarned, however, that modifier GZ claims might be subject to complex medical reviews, which can slow claims and create logjams in your billing processes. However, CMS has a new policy going into effect to deny those claims instantly.

In black and white: "Effective for dates of service on and after July 1, 2011, contractors shall automatically deny claim line(s) items submitted with a GZ modifier," states Transmittal 2148. Your explanation of benefits will list the denial codes CO (Provider/supplier liable) and 50 (These services are non-covered services because this is not deemed a 'medical necessity' by the payer).

Plan ahead: Don't force yourself to resort to modifier GZ. Have a policy in place to collect ABNs before the procedure or service has been provided, when you think the service will be denied because it doesn't meet the Medicare's medical necessity requirements.

To read Transmittal 2148, visit www.cms.gov/transmittals/downloads/R2148CP.pdf.