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Pathology/Lab Coding Alert

3 Modifiers Tell the Tale of ABN Status

Published on Wed Jul 06, 2005

Get Medicare to tell patients they must pay

When you tell a patient he'll have to pay for a lab test, you want the insurer to send the same message. Modifiers are your best shot at getting patients to pay for noncovered tests.

Medicare and some other payers will back up your message that a lab test is not covered when you use the proper modifiers to indicate whether you've issued an advance beneficiary notice (ABN).

Don't miss: You typically use one of three modifiers with ABNs: GA, GY, and GZ, says Jean Acevedo, LHRM, CPC, CHC, senior consultant for Acevedo Consulting in Delray Beach, Fla. 

Modifiers Explain ABN Status

By using the proper modifier, Medicare's explanation of benefits (EOB) will notify the patient when he has to pay. Use the following descriptions to guide your modifier choice:

  •  GA - Waiver of liability statement on file.

    Use modifier GA when you've issued an ABN because you expect Medicare to deny the service as not medically necessary. This might include tests ordered without a payable diagnosis code or those ordered more frequently than covered.

    Example: A physician orders a screening Pap smear (P3000, Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision), but the lab does not know when the patient last had the test. Because Medicare only covers one Pap test every three years unless the physician suspects cervical abnormalities, you should get the patient to sign an ABN acknowledging that she will have to pay for the test if she has had a Pap smear within the last three years.

  •  GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.

    By law, Medicare excludes some medical treatments, such as many screening tests, and you may want to inform patients of this fact. Although you're not required to issue an ABN for excluded procedures, doing so is a courtesy to the patient and may help you get paid. When you report modifier GY in these cases, Medicare will generate a denial notice that the patient may use to seek payment from secondary insurance - helping your lab avoid unpaid claims.

  •  GZ - Item or service expected to be denied as not reasonable and necessary.

    You don't want to have to use modifier GZ - it means you didn't issue an ABN when you should have. Thus, you can't bill the patient, and the carrier probably won't pay you.

    Example: A physician orders PT (CPT 85610 , Prothrombin time) for a patient with a diagnosis of unspecified Gram-negative septicemia (038.40, Septicemia due to other Gram-negative organism, unspecified). The lab doesn't issue an ABN but discovers before billing that Medicare's PT National Coverage Determination only covers the test for unspecified septicemia (038.9, Unspecified septicemia). Expecting a denial, the lab bills 85610-GZ.

    Why use modifier GZ at all if you still won't 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.

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