Pain Management Coding Alert

Question: When should the practice get a signed advance beneficiary notice (ABN), and how do I report ABN-related modifiers?

Ohio Subscriber

Answer: You must issue the ABN when:

• You believe Medicare may not pay for an item or service;
• Medicare usually covers the item or service; and
• Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

The following are the Medicare ABN modifiers:

GA: (Waiver of liability statement issued as required by payer policy, individual case). Use this modifier to report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN, but you must have it available on request.

GX: (Notice of liability issued, voluntary under payer policy). Use this modifier to report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier in combination with modifier GY.

GY: (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit). Use this modifier to report that Medicare statutorily excludes the item or service or the item or service does not meet the definition of any Medicare benefit. You may use this modifier in combination with modifier GX.

GZ: (Item or service expected to be denied as not reasonable and necessary). Use this modifier to report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued.