Practice Management Alert

Question: Im about to send a bill to Medicare for a service Im pretty sure will be denied. Should I use modifier -GA or -GY?
    
Pennsylvania Subscriber

 
Answer: Many providers arent clear on the difference between modifiers -GA and -GY, says Jennifer Darling, insurance and collection specialist with the Center for Oncology Research & Treatment in Dallas. Many services are statutorily excluded from Medicare payment, and you dont need a signed advance beneficiary notice (ABN) to bill the patient for these non-covered services, such as a preventative well-woman exam (99387).
 
Since Medicare wont pay for such services, you dont have to submit a bill to the program for them. However, sometimes a patient will insist that you do so, Darling points out. In such a case, you should use the -GY modifier, which notifies Medicare that youre aware that the service isnt covered, but youre billing simply to obtain a denial. For more information on -GY, go to http://cms.hhs.gov/medlearn/modchtgy.pdf.
 
By contrast, youd use the -GA modifier when Medicare imposes time or coverage limits on a service and you are unsure that Medicare will cover it. In this case, the patient must sign an advance beneficiary notice. For example, drug codes such as the chemotherapy codes have time constraints, and so do pathology and radiology services. In the case of bone density scans, you can bill them once every two years in the absence of other medical necessity indicators. For more information on -GA, go to http://cms.hhs.gov/medlearn/modchtga.pdf.
 
The -GZ modifier is a close cousin to -GY and -GA, and should be used on codes that usually are covered, but indicates that the way the service was provided makes it not medically necessary, Darling adds. The main purpose of the -GZ modifier is to safeguard your practice from being looked at as possibly committing some type of fraud and expecting payment for services you know are not medically necessary, she says. For more information on -GZ, go to http://cms.hhs.gov/medlearn/modchtgz.pdf.