Pathology/Lab Coding Alert

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

Iowa 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. Using modifier GA means that you can bill the patient for the service.
• 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 might do this as a courtesy to the patient before billing them, even though Medicare doesn't require an ABN in this case. 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, but no ABN was issued. You cannot bill the patient for the service if you have to use modifier GZ.

Note: You should be using the latest ABN form approved by the Office of Management and Budget, for use from June 21, 2017 through March 2020. Although this form doesn't vary from the previous form, except for the date, CMS mandates use of the new version.