Oncology & Hematology Coding Alert

Use this table to clear your ABN modifier confusion.

Most of the time, when Medicare payers process denials in a speedy fashion, that's bad news for your practice. But when you use modifier GZ, you're already expecting a denial, so it helps you take the claim off of your practice's to-do list. CMS will make these denials happen faster with a new policy to immediately deny all services with modifier GZ appended.

How modifier GZ works: If you're still wondering why anyone would want a quick denial, here's a closer look at how modifier GZ works.

If the physician performed a service you expect Medicare to find medically unnecessary based on the agency's rules, and there's no 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 for the service. The advantage of reporting modifier GZ is avoiding the potential for fraud and abuse allegations. This modifier tells Medicare that you believe you're submitting the code for a service CMS won't cover and expect Medicare not to pay for it.

Get to the Bottom of Denial Update

CMS's new policy to have modifier GZ trigger an instant denial should help prevent the current problem of the claims being subject to complex medical reviews, which can slow claims and create delays in your billing processes.

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). To read the complete rule, released in Transmittal 2148, visit www.cms.gov/transmittals/downloads/R2148CP.pdf.

Best bet: Plan ahead to limit circumstances requiring GZ use. You should only append GZ in uncommon situations where the practice missed the opportunity to obtain the ABN or where the practitioner instructed the staff to provide the service anyway, based on medical judgment under the circumstances. Your practice should have a policy in place to collect ABNs when necessary.

Shore Up Your ABN Modifier Knowledge

The multitude of ABN modifiers is a common cause of confusion. Use the modifier GZ policy change as an opportunity to refresh your knowledge of all ABN-related modifiers. This table can help you sort out proper use for your claims.