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Radiology Coding Alert

News Brief:

Reporting Noncovered Medicare Services

Published on Sat Sep 01, 2001

Policy-makers announced the deletion of HCPCS modifier -GX (service not covered by Medicare), which allows radiologists and other providers to bill Medicare for noncovered services to get a denial, after which the physician can submit the charges to a secondary payer. When the modifier is reported, Medicare knows practices are not trying to beat the system and obtain inappropriate reimbursement, but rather that they know it isnt covered and need an explanation of benefits (EOB) to confirm the denial.
 
Two modifiers will take the place of the -GX, which was used often. The new modifiers more clearly define the reasons for denial. Modifier -GY will be used to report an item or service statutorily noncovered, while -GZ will describe an item or service not reasonable and necessary. These new modifiers may be used beginning Jan. 1, 2002.
 
Modifier -GY is assigned for services that Medicare, by law, cant pay for. These services are assigned a status code of N in the Medicare fee schedule and include many screening evaluations such as routine chest x-rays during annual checkups or cardiac scoring (an investigational procedure often reported with 76499, unlisted diagnostic radiologic procedure).
 
But, coders should append modifier -GZ when national or local Medicare policy has excluded specific services as not reasonable or necessary. An example is bone density scans (e.g., 76075, dual energy x-ray absorptiometry [DEXA], bone density study, one or more sites; axial skeleton [e.g., hips, pelvis, spine]), which are not covered unless certain prerequisites have been met. The -GZ modifier should be assigned in conjunction with the -GA modifier, which informs Medicare that an advance beneficiary notice (ABN) has been obtained from the patient for these services.
 
With its implementation of -GY and -GZ, Medicare has also added two new Q codes:
 
Q3015 -- item or service statutorily noncovered, including benefit category exclusion (used only when no specific code available)
 
 Q3016 -- item or service not reasonable and necessary (used only when no specific code available).
 
These codes should be assigned when no CPT Codes or HCPCS Codes is available to describe the services rendered -- for example, when the noncovered or not medically indicated service is represented by a CPT code for unlisted procedures (xxx99 codes).
 
More information on these new modifiers and Q codes may be found in Program Memorandum B-01-30, available on the HCFA Web site, www.hcfa.gov.

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