Pathology/Lab Coding Alert

Question: Our lab performed a Pap test for a Medicare patient that exceeds the frequency limitations for the test. Neither the ordering physician nor we obtained a signed ABN. How should we bill for the test? 

Ohio Subscriber

Answer:  If your lab does not have a signed advance beneficiary notice (ABN) on file, you may append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the procedure code that describes the Pap test. Because you’ve exceeded the frequency limitation, Medicare will consider this a non-covered service.

Modifier GZ communicates that you are claiming a non-covered service and that you realize Medicare will not pay for the service.

Option: Claims with modifier GZ may lead to automatic denial. Monitor the claim and make sure you write off the charge if Medicare does deny the claim.

Avoid: Remember that using modifier GZ means you can’t bill the patient or secondary insurance for the service.