Ophthalmology and Optometry Coding Alert

Question: I heard that modifier -GX is being replaced. What should I use instead?

Ohio Subscriber

Answer: There are two new modifiers that replaced modifier -GX (service not covered by Medicare) as of Jan. 1, 2002. Medicare says to use the new modifiers, modifier -GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) and modifier -GZ (item or service expected to be denied as not reasonable and necessary), to bill for benefits that are not covered because they are not reasonable and necessary. Modifier -GX is discontinued.
 
Modifier -GY: Use modifier -GY for refractions and for any other circumstance in which you want to indicate that the service is not a benefit of the Medicare program (i.e., not covered by statute.) Refractions have not been a benefit of the Medicare program since its inception. This is spelled out in the Medicare Carriers Manual. No advance beneficiary notice (ABN) is required.
 
Modifier -GZ: Do not use modifier -GZ for refractions. Use it to indicate that you expect Medicare will deny a service as not reasonable and necessary but an ABN has not been signed by the patient. Statutorily non-covered services do not require an ABN form. Medicare created modifier -GZ to indicate that no ABN was required to collect from the patient.
 
Use modifier -GZ when, due to an oversight, the patient is not given an ABN and should have been, or did not sign the ABN that was given. Your goal should be to not need modifier -GZ. But sometimes, you might. It would most likely be used to denote a service that is not covered in a certain case (the one you're filing with -GZ), but which under other circumstances would be covered.
 
For example, the ophthalmologist performs a blepharoplasty (15823, blepharoplasty, upper eyelid; with excessive skin weighting down lid) that is borderline cosmetic. The ophthalmologist files the claim. If the practice does not have a signed ABN and Medicare denies it, the doctor won't be able to collect from the patient.
 
If you have not obtained an ABN when you expect the procedure may be considered not medically necessary, that is your mistake, and -GZ denotes the error. Your penalty: you cannot collect from the patient. It should be an uncommon occurrence. If a procedure, such as the blepharoplasty example listed above, is cosmetic, the physician knows before he or she performs it and you should obtain an ABN.
 
Anytime you file an unlisted procedure code and use modifiers -GY or -GZ, enter additional information to describe the service on item 19 or submit it as an attachment.
 
Note: Use modifier -GA when you expect Medicare will deny a service as not reasonable and necessary and an ABN is on file. If a signed ABN is on file, the fee can be collected from the patient.
 
The program memorandum, dated Sep. 25, 2001, can be viewed online at www.hcfa.gov/pubforms/transmit/B0158.pdf