Neurology & Pain Management Coding Alert

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 26, 2001, CMS released program memorandum B-01-30 announcing the replacement of modifier -GX by modifiers -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) and -GZ (Item or service expected to be denied as not reasonable and necessary), effective Jan. 1, 2002. These new modifiers are meant to describe the reason why Medicare will not allow the service or procedure.

Note: Program Memorandum B-01-03 may be downloaded from the CMS Web site.Physicians should apply modifier -GY to the appropriate code when billing a general program exclusion service to Medicare. Use modifier -GZ when you bill a service that doesn't pass medical-necessity edits and the physician did not obtain a signed ABN from the patient. Claims submitted with modifier -GZ will not be denied automatically based on a particular CPT code. The carrier may, however, deny the claim based on other criteria such as diagnosis to procedure coding.

According to the memo, "Anytime the modifiers -GY or -GZ are used, providers and suppliers must explain why the services or supplies are being submitted. This information is entered in Item 19 of Form [CMS] 1500. For the electronic format, providers and suppliers must report this information in the claims level note. If space for additional narrative is needed, the provider or supplier must enter the qualifier 'ADD' in NTE01, then enter the additional narrative in NTE02." CMS-approved examples of explanatory language include "Claim submitted to receive denial for secondary payer" or "Service performed by family member."

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education, Absecon, N.J.