Orthopedic Coding Alert

Heres when to append modifiers GA, GY, and GZ.

Services a patients insurer doesn’t cover (but the patient requests or surgeon recommends) could mean your practice is at risk for fronting the bill, but you can save yourself money and headaches by reaching for an advance beneficiary notice (ABN) and appending modifier GA.

Your patient will be the one paying instead.

Modifier GA Gets You Paid on Injection Overuse

In some circumstances, you may not know for certain if Medicare will cover the service. When in doubt, protect yourself and request that the patient sign an ABN.

Beware: You should never give out ABNs as a standard, across-the-board practice. You should use ABNs only when they apply.

The proper time to have the patient sign an ABN is before providing the service or procedure for which you want to recoup payment. The ABN must be verbally reviewed with the beneficiary or his/her representative. Any questions the patient raises must be answered before it is signed.

After the patient has signed the ABN, you must inform Medicare by appending modifier GA (Waiver of liability statement on file) to the CPT^® code describing the (suspected) noncovered service or procedure. In other words, you should use modifier GA when you believe the service is not covered, and the office has a signed ABN on file.

When Medicare sees the GA modifier, it will send an explanation of benefits (EOB) to the patient confirming that he is responsible for payment. If you don’t append the modifier, Medicare will not inform the patient of his responsibility.

Example: A patient with chronic lower-back pain requests an epidural injection (62311, Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

This patient has already received six such injections in the past 12 months -- the maximum number his Medicare carrier will reimburse in a one-year period without extenuating circumstances.

Because you are unsure if Medicare will cover the procedure, you ask the patient to sign an ABN. The ABN outlines the service the surgeon will provide (epidural injection) and the reason Medicare may reject payment (excessive frequency).

The surgeon provides the injection, and you report the service using 62311 with modifier GA appended. In this case, because the patient has exceeded the frequency guidelines, Medicare denies the claim and sends the patient an EOB.

Keep in mind: The patient has to sign the ABN form prior to or at the time of service; otherwise the form is not valid. When the claim is denied without an ABN, Medicare will not allow you to bill the patient for the service.

Use GY for Investigational X-Stop Procedure

You don’t need to ask the patient to sign an ABN when the surgeon performs procedures or services that Medicare never covers.

The physician may still ask the patient to sign an ABN to verify that he is responsible for the services cost. And some patients request that the physician submit a claim for noncovered services in hopes of receiving coverage from a secondary insurer.

In such cases, you should report the appropriate CPT^® code for the surgeons services with modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit or, for non-medicare insurers, is not a contract benefit) appended. Medicare will generate a denial notice for the claim, which the patient may use to seek payment from secondary insurance.

Example: A patient with lumbar spinal stenosis reports to the orthopedist. The orthopedist suggests the patient undergo an X-Stop on three levels. Medicare considers the X-Stop procedure investigational and wont pay for the procedure. The patient agrees to undergo the procedure anyway, and you ask him to sign an ABN.

For the surgery, you report 0171T (Insertion of posterior spinous process distraction device [including necessary removal of bone or ligament for insertion and imaging guidance], lumbar; single level) for the first level and two units of +0172T (... each additional level [List separately in addition to code for primary procedure] [Use 0172T in conjunction with code 0171T]) for the next two levels.

No ABN? Turn to GZ

If you should have had a patient sign an ABN but failed to do so, you should append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT^® code describing the noncovered service the physician provided.

You don’t want to be in the position to use modifier GZ, however, because it means that you probably wont get paid. By notifying Medicare using modifier GZ, you reduce the risk of allegations of fraud or abuse when filing claims that are not medically necessary.