Orthopedic Coding Alert

Question: Do we have to report modifiers -GA and -GX for all claims that we know Medicare will deny?

Texas Subscriber

Answer: Even when you know that Medicare will deny a given service, you must still file a claim with the patients carrier. Append modifier -GA (Waiver of liability statement on file) to all CPT codes covered by an advance beneficiary notice (ABN). An ABN informs Medicare beneficiaries that Medicare may not cover a particular service or procedure, and it notifies the patient of his or her responsibility to pay if Medicare does not. The ABN must clearly identify the service rendered and state the reason that Medicare may deny it.

Append modifier -GA only if youre billing a service that Medicare may not deem medically necessary. The -GA modifier tells Medicare that the patient signed an ABN, and the explanation of benefits will note that the patient is responsible for payment.

For instance, you may need an ABN if a patients diagnosis does not warrant a procedure based on Medicare guidelines, or if the physician provides legitimate services that exceed Medicare frequency rules.

An ABN is not necessary when the orthopedist performs procedures or services that Medicare never covers (such as acupuncture). The physician, however, may still ask the patient to sign an ABN to verify that he or she is aware of being responsible for the services cost.

Some patients request that the physician submit a claim for noncovered services in hopes of receiving coverage from a secondary insurer. Until 2002, providers submitted such claims using modifier -GX (Service not covered by Medicare), which indicated that Medicare should issue a denial notice, thus allowing the patient to pursue payment from other insurance.

On April 26, 2001, CMS released program memorandum B-01-30 announcing that modifier -GX would be replaced by modifiers -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) and -GZ (Item or service expected to be denied as not reasonable and necessary), effective Jan. 1, 2002. These new modifiers describe the reason why Medicare will not allow the service or procedure.

Append modifier -GY to the appropriate code when billing a general program exclusion service to Medicare. Use modifier -GZ when you bill a service that doesnt pass medical-necessity edits and the physician did not obtain a signed ABN from the patient.

Medicare will not automatically deny claims submitted with modifier -GZ simply because they are billed with a particular CPT code. The carrier, however, may deny the claim based on other criteria such as diagnosis to procedure coding.

According to the memo, "Anytime the modifiers -GY or -GZ are used, providers and suppliers must explain why the services or supplies are being submitted" on Item 19 of the CMS-1500 form. CMS-approved examples of explanatory language include "Claim submitted to receive denial for secondary payer" or "Service performed by family member."