Pulmonology Coding Alert

Question: When billing Medicare services, how should I use modifiers -GY, -GZ and -GA?

Vermont Subscriber

Answer: These modifiers are used to bill Medicare for noncovered services to obtain the denial required to bill a secondary payer that may reimburse for the service or item. Effective Jan. 1, 2002, Medicare no longer accepts modifier -GX (Service not covered by Medicare), which formerly was used to report a noncovered Medicare service. Instead, providers must use modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit), -GZ (Item or service expected to be denied as not reasonable and necessary) or -GA (Waiver of liability statement on file).

Modifier -GY is used to report services or items that are excluded from Medicare or do not meet the Medicare benefit definition. This will include most preventive services such as physical examinations, which may, however, be covered as part of a wellness benefit by a secondary payer. Modifiers -GZ and -GA are used to bill an item or service that is normally covered by Medicare but, in a particular instance, the physician believes the service or item will be denied because it does not meet medical-necessity requirements. You should use modifier -GA if the provider has obtained an advance beneficiary notice (ABN) and report modifier -GZ if the patient has not signed an ABN.

Advice for You Be the Coder and Reader Questions was provided by Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia; Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa.; Mary Mulholland, RN, BSN, CPC, reimbursement analyst at the University of Pennsylvania department of medicine in Philadelphia; and Walter O'Donohue, MD, FCCP, FACP, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP, Omaha, Neb.