Question:
Which modifier applies when the physician performed a noncovered service for a Medicare patient, but we didn't get an ABN?New Jersey Subscriber
Answer:
If the physician performed a non-covered service 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 describing the non-covered service. The advantage to reporting modifier GZ is avoiding the potential for fraud and abuse allegations. This modifier tells Medicare that you know you're submitting the code for a non-covered service, and you expect them not to pay for it.
Watch out:
Currently, your modifier GZ claims may be subject to complex medical reviews, which can slow claims and create logjams in your billing processes. However, CMS has a new policy going into effect to deny those claims instantly.
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).
Plan ahead:
Don't allow yourself to resort to modifier GZ. Have a policy in place to collect ABNs when necessary. To read Transmittal 2148, visit
www.cms.gov/transmittals/downloads/R2148CP.pdf.