Pulmonology Coding Alert

CMS has posted a new chart on its Web site (www.hcfa.gov/medlearn/refabn.htm) instructing physicians and Medicare contractors regarding the use of modifiers -GA, -GZ and -GY when billing noncovered services. These modifiers alert Medicare contractors that a physician or other provider believes that Medicare will not pay for a service or item. The -GA and -GZ modifiers are used to bill normally covered services that the physician does not believe meet medical-necessity criteria in a particular instance. Modifier -GY is used to bill services that are never covered by Medicare to obtain a denial to bill a secondary insurer that may cover the service.

CMS says Medicare carriers are not supposed to consider the modifiers when determining payment. A pattern of omitting the -GA and -GZ modifiers may be construed as fraud and abuse.

Specific clarifications related to each of the modifiers are as follows:

Modifier -GA. The -GA modifier is used for services a provider believes will be denied on medical-necessity grounds (not reasonable or necessary) when an advance beneficiary notice (ABN) has been obtained or the patient's refusal to sign the ABN has been properly witnessed in the case of an assigned claim. If Medicare denies the claim, the beneficiary is wholly liable to pay for the services. However, if the provider does not bill using modifier -GA, the beneficiary does not have to pay for the service.

Modifier -GZ. Providers should use the -GZ modifier on unassigned claims for all physician services when the patient has refused to sign an ABN for a provided service. If the claim is denied, the beneficiary is generally not considered liable, but the provider may be able to collect for the service if it is found not liable for an unassigned claim. In such a case, the physician would have to prove that he or she had no way of knowing a service was not medically necessary and, therefore, would be denied. Reimbursement experts say this is difficult to prove. Providers are free not to use the -GZ modifier, but its use helps greatly reduce risks of fraud and abuse allegations.

Modifier -GY. The -GY modifier is used to denote statutorily excluded services, such as routine physical examinations, preventive health counseling and lab tests in the absence of signs and symptoms. Providers do not collect an ABN in such situations. Medicare often automatically denies claims that contain modifier -GY, which expedites the process for providers that require a denial to bill a secondary insurer for the service.