Urology Coding Alert

Question: I’m working on a claim for a Medicare patient that includes an advance beneficiary notice (ABN). I know we need to include a modifier to indicate that we gave the patient an ABN, but I don’t know what the options are. Can you give me a rundown of the ABN modifiers?

Tennessee Subscriber

Answer: In short, an ABN is a document that you provide to a Medicare patient ahead of a service or procedure if you think that Medicare might not pay for part (or all) of the service your physician intends to perform. The goal of an ABN is to give the patient as much information about the procedure and insurance coverage as possible so the patient can make an informed decision about whether to proceed with the treatment. The ABN also alerts the patient that you don’t expect insurance to cover the cost, so that responsibility will fall to the patient.

A number of situations may prompt an ABN issuance. Medicare designed the following modifiers to make clearer why the provider issued the ABN:

• GA (Waiver of liability statement issued as required by payer policy, individual case): Use this modifier when you issue a mandatory ABN for a service as required, and it is on file.
• GX (Notice of liability issued, voluntary under payer policy): Use this modifier when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded, or is not a Medicare benefit.
• GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit): Use this modifier to report that Medicare statutorily excluded the item or service; or the item or service does not meet the definition of any Medicare benefit.
• GZ (Item or service expected to be denied as not reasonable and necessary): Use this modifier when you expect Medicare to deny payment of the item or service due to a lack of medical necessity, and no ABN was issued.