Neurosurgery Coding Alert

HCFA has deleted modifier -GX (service not covered by Medicare) and replaced it with two new modifiers, one of which makes surgeons responsible for deciding if the procedures they perform may not be considered "reasonable and necessary" by Medicare.

Two new codes, Q3015 (item or service statutorily non-covered, including benefit category exclusion [use only when no specific code is available]) and Q3016 (item or service not reasonable and necessary [use only when no specific code is available]), have also been added to HCPCS.

According to an April 26 Medicare transmittal (B-01-30), modifier -GX has been replaced by modifiers -GY (item or service statutorily non-covered) and -GZ (item or service not reasonable and necessary).

Modifier -GY and code Q3015 perform the same function as did modifier -GX, which was used to obtain a denial for a noncovered service so a third-party carrier or the patient could be billed.

Modifier -GZ and code Q3016 appear to force the surgeon to determine if a procedure he or she considers medically necessary is "reasonable and necessary" according to HCFA. The memorandum states, "The new modifiers, -GY and -GZ, must be used when a specific code is available but the provider or supplier wants to indicate that the item or service is not covered or is not reasonable and necessary" [emphasis added].

The transmittal further elaborates:

The memorandum also states, "When a service is performed or item supplied that is not reasonable and necessary under the specific circumstances, it is the responsibility of the provider or supplier to notify the beneficiary in writing through the use of the advance beneficiary notice." Under these circumstances, the provider or supplier is instructed to file the services or items with the -GA modifier (waiver of liability statement on file) and Q3016 or modifier -GZ, not instead or in place of them.