Oncology & Hematology Coding Alert

Question: I’m filing a claim that includes an advance beneficiary notice (ABN) for a Medicare patient. I know that we need to include a modifier to indicate that we sent out ABN, but I cannot find them anywhere. Could you give me a rundown of the ABN modifiers?

Tennessee Subscriber

Answer: In short, an ABN is a document you provide to a Medicare patient ahead of a service or procedure if you think Medicare might not pay for part, or all, of a service. The ABN is meant to give the patient as much information as possible before deciding whether to proceed with a treatment.

When you issue an ABN, it can be prompted by a number of situations. Medicare designed the following modifiers to clarify why the provider issued the ABN:

• GA (Waiver of liability statement issued as required by payer policy, individual case): Use this modifier when you issue a mandatory ABN for a service as required, and it is on file.
• GX (Notice of liability issued, voluntary under payer policy): Use this modifier when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit.
• GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit): Use this modifier to report that Medicare statutorily excludes the item or service; or the item or service
• does not meet the definition of any Medicare benefit.
• GZ (Item or service expected to be denied as not reasonable and necessary): Use this modifier when you expect Medicare to deny payment of the item or service due to a lack of medical necessity, and no ABN was issued.

You can find these modifiers defined in the HCPCS code set manual text.