Otolaryngology Coding Alert

Question: We have patients sign an ABN for a certain procedure in our office that may or may not be covered by their insurance. We include modifier GA on the claim for Medicare patients, but aren’t sure how to handle patients with private insurance. Do we still report modifier GA to let the insurance company know we have a signed waiver on file if they deny the claim?’

Connecticut Subscriber

Answer: The correct approach depends on the insurer.

Most private insurers don’t recognize the modifier GA (Waiver of liability statement issued as required by payer policy, individual case) – but others do. Most private insurers don’t require GA on the claim, but verify the payer’s policy before submitting the claim.

Medicare policy: Whenever a procedure might not be covered, Medicare requires an advanced beneficiary notice (ABN) or waiver signed by the patient acknowledging that he or she may have to pay for the procedure if Medicare does not find it medically necessary. When you file with the GA modifier, Medicare indicates that the doctor may bill the patient if Medicare denies the procedure because it lacked medical necessity.

When a claim has a GA modifier and Medicare denies the claim, the patient’s explanation of benefits (EOB) states that the doctor may bill the patient. Without modifier GA, Medicare assumes that a valid ABN is not on file, and the EOB on denial from Medicare tells the patient that the doctor may not bill the patient.