Question: I've heard that guidelines for Medicare modifiers -GA and -GX have changed. Is this true? What is the correct way to apply these modifiers? Texas Subscriber Answer: Even when Medicare is not expected to cover a given service/procedure, the provider must still file a claim with his or her Medicare carrier. Modifier -GA (Waiver of liability statement on file) must be appended to all CPT codes covered by an advance beneficiary notice (ABN). An ABN is a written notice provided by the physician to inform a Medicare beneficiary that Medicare may not cover a particular service or procedure and asks the patient to pay. The ABN must clearly identify the service/procedure to be rendered and state the reason it may not be covered.
In addition, physicians "must provide ABNs before they render services that they know Medicare does not consider medically necessary or will not reimburse." Append modifier -GA only when billing a service that doesn't pass medical-necessity edits and you obtained a signed ABN from the patient. The -GA modifier will alert Medicare to note on the explanation of benefits that the patient is responsible for payment. For instance, an ABN may be needed if a patient's diagnosis does not warrant a procedure per Medicare guidelines, or if the physician provides legitimate services that exceed Medicare frequency guidelines. For example, most carriers will pay for reprogramming of implanted deep-brain stimulators (DBS) (95970-95973) only once every 30 days. If the neurologist provides this service more frequently due to adverse patient reactions, he or she should obtain an ABN, provide the service and file a claim of 9597x-GA. If Medicare denies the service based on frequency limits, it will note on the claim that the patient is responsible for payment. An ABN is not needed when providing procedures/ services that Medicare never covers. However, it is allowed and the physician may ask the patient to sign to verify that he or she is aware of being responsible for the cost of the service/procedure. Note: Medicare updated and standardized its ABN form effective July 1, 2001 (CMS memorandum A-01-77, change request 1192, dated June 27, 2001). The ABN is a simple form that may be reproduced on the individual provider's letterhead. A sample ABN (OMB Approval #0938-0566, form #HCFA-R-131-G) with instructions may be found on the CMS Web site,
www.cms.gov. In some cases, the patient may request that the physician submit a claim for noncovered services in hopes of receiving coverage from a secondary insurer. Until this year such claims were submitted using modifier -GX (Service not covered by Medicare). The modifier indicated that Medicare should issue a denial notice, thus allowing the patient to pursue payment from other insurance. On April [...]
