ahodge90
Networker
I have a question regarding when and when I do no need an ABN. Is there anyone out there that can help me understand this better I would really appreciate it!
thanks!!
thanks!!
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Wiki routine footcare questions
- Thread starter ahodge90
- Start date
amyjph
True Blue
Bernadette10
Guru
Another question about this - when there's no covered diagnosis for routine footcare for Medicare and no ABN was signed, should I add modifier GY or GZ to the procedure code? I thought GZ was more for noncovered diagnoses since GY is for something that's never covered (statutorily excluded), and dystrophic nail trimming and callus trimming could be covered if there was a covered diagnosis. But when GZ is used, the patient can't be billed, so then the clinic wouldn't be paid for the service (if the patient was only seen for routine footcare), which doesn't seem right.
Example - patient comes in for onychomycotic nail trim G0127 and callus trim 11055. Dx are B35.1 and L84. No other diagnoses, and no ABN was signed. GY or GZ?
https://symbiosisrcm.com/using-modifiers-gy-and-gz/
Modifier -GY: Appending -GY modifier to the CPT code enables one to identify an “item or service is statutorily excluded or the service does not meet the definition of Medicare Benefit”. This will automatically create a denial and beneficiary may be liable for all charges whether personally or through other insurance, ( for example: when a beneficiary wants new eye glasses and wants to get a denial through Medicare for secondary payer purposes), claim should be submitted with -GY modifier. This way claim may be processed faster than it would be without -GY modifier. ABN’s ( Advanced Beneficiary Notices) are not an issue for statutory exclusions.
Modifier -GZ: You should append -GZ modifiers to CPT codes when you think a service will be denied because it does not meet Medicare policy standards for medically necessary care and you didn’t get an ABN or patient refused to sign an ABN and you nevertheless, did furnish the sevices. By using -GZ modifier, you are notifying Medicare that you know an ABN should have been signed but was not and that you recognize you made an error. This modifier is a measure of good faith towards Medicare. Note: You cannot bill patient for these services.
Example - patient comes in for onychomycotic nail trim G0127 and callus trim 11055. Dx are B35.1 and L84. No other diagnoses, and no ABN was signed. GY or GZ?
https://symbiosisrcm.com/using-modifiers-gy-and-gz/
Modifier -GY: Appending -GY modifier to the CPT code enables one to identify an “item or service is statutorily excluded or the service does not meet the definition of Medicare Benefit”. This will automatically create a denial and beneficiary may be liable for all charges whether personally or through other insurance, ( for example: when a beneficiary wants new eye glasses and wants to get a denial through Medicare for secondary payer purposes), claim should be submitted with -GY modifier. This way claim may be processed faster than it would be without -GY modifier. ABN’s ( Advanced Beneficiary Notices) are not an issue for statutory exclusions.
Modifier -GZ: You should append -GZ modifiers to CPT codes when you think a service will be denied because it does not meet Medicare policy standards for medically necessary care and you didn’t get an ABN or patient refused to sign an ABN and you nevertheless, did furnish the sevices. By using -GZ modifier, you are notifying Medicare that you know an ABN should have been signed but was not and that you recognize you made an error. This modifier is a measure of good faith towards Medicare. Note: You cannot bill patient for these services.
podcoder70
Expert
Hi Bernadette, these are all very good questions. The ABN is to be used if there is presumption of non coverage of an item or service that is normally covered. For example, if you dispense a Cam boot and you know the patient had one previously or suspect they had a "same/similar" item, you would have them sign an ABN. In the case of "routine foot care", technically speaking, it is not covered by Medicare and thus does not require an ABN. With that said, the patient needs to be notified that their treatment is not covered prior to treatment. The only reason you would use the G modifiers is if there is a "secondary" insurance (not supplement--they only pay what Medicare covers) that might pay. In that case you would add the GY modifier. In most cases, since most patients have a "medicare supplement" plan, you would not send a claim, the treatment would be CASH pay at the time of service.
I should add that some of the Medicare jurisdictions pay for callus and nail treatment if the provider can document that the patient has pain. Noridian for example pays for 11721 and 1105x with the secondary diagnosis M79.67_. I hope this helps.
I should add that some of the Medicare jurisdictions pay for callus and nail treatment if the provider can document that the patient has pain. Noridian for example pays for 11721 and 1105x with the secondary diagnosis M79.67_. I hope this helps.
Bernadette10
Guru
Thanks for your help. These patients all have Medicare or a Medicare supplement without secondary insurance, but if I submit the charges without a modifier, they're sent back into my worklist by the software as denied for noncovered diagnosis, so I have to add a G modifier to get them to submit to the insurance, even though they won't pay anyway. I work remotely, and from what we've been told, the office is not having the patients sign an ABN, and I've never seen one in the system. I don't know if the office is collecting payment at the time of service. The MAC is Novitas, and so far I haven't seen any diagnoses on the notes that would be covered for callus and nail trimmings. So is GZ a better choice if there's no secondary insurance?
podcoder70
Expert
My pleasure. I looked up Novitas RFC guidelines and this is what it says: "Submit modifier GY with items or services that are statutorily excluded or that do not meet the definition of any Medicare benefit. GY may be appropriate when routine foot care does not meet Medicare coverage. You may offer the beneficiary a CMS ABN. This form is optional for services that are statutorily excluded from Medicare coverage."
So GY looks like the way to go and the ABN is optional if the service is statutorily excluded, which in this case it is. Novitas also says:
"Ordinarily, a physician or healthcare provider does not submit a claim for non-covered services. However, if the beneficiary (or his/her representative) believes that a service may be covered or desires a formal Medicare determination, the physician or healthcare provider must file a claim for that service to effectuate the beneficiary's right to a determination.
Submit HCPCS modifier GY to denote that 'the item or service is statutorily excluded or does not meet the definition of any Medicare benefit.' Maintain documentation that the service is being submitted at the beneficiary's insistence. You may also submit HCPCS modifier GY when filing claims to obtain a Medicare denial for secondary payer purposes."
With no secondary, there is no obligation to bill medicare.
I don't know what the relationship is with the provider, but if there is a way to notify the office of what is non covered they should be told. With the new "no surprises" act, these patients should be notified ahead of time that their service is not covered. You could share with them the list of covered diagnoses perhaps.
So GY looks like the way to go and the ABN is optional if the service is statutorily excluded, which in this case it is. Novitas also says:
"Ordinarily, a physician or healthcare provider does not submit a claim for non-covered services. However, if the beneficiary (or his/her representative) believes that a service may be covered or desires a formal Medicare determination, the physician or healthcare provider must file a claim for that service to effectuate the beneficiary's right to a determination.
Submit HCPCS modifier GY to denote that 'the item or service is statutorily excluded or does not meet the definition of any Medicare benefit.' Maintain documentation that the service is being submitted at the beneficiary's insistence. You may also submit HCPCS modifier GY when filing claims to obtain a Medicare denial for secondary payer purposes."
With no secondary, there is no obligation to bill medicare.
I don't know what the relationship is with the provider, but if there is a way to notify the office of what is non covered they should be told. With the new "no surprises" act, these patients should be notified ahead of time that their service is not covered. You could share with them the list of covered diagnoses perhaps.
mburke81
Networker
I too am not clear on when to use the GY. My providers do not get ABN's signed. Humana returns these with GY as no patient responsibility. I thought GY was patient responsibility and the GZ was used when it is not. Is there any reference anywhere as to podiatry routine foot care and the GY, GZ modifier usage?
I use the GY if there is not a diagnosis from the covered list.
I use the GZ if they do have a covered diagnosis, but it is withing the 61 days.
My providers are asking for something in writing and i am not able to find any.
Thanks in advance for your time !
I use the GY if there is not a diagnosis from the covered list.
I use the GZ if they do have a covered diagnosis, but it is withing the 61 days.
My providers are asking for something in writing and i am not able to find any.
Thanks in advance for your time !
podcoder70
Expert
Also, there are good references posted by user Amyjph earlier in this thread.
For RFC, if the patient is not covered, for any reason...ie: no risk factors or too early...bill with the GY modifier, no ABN is required, the service is just NOT covered. Frankly, there is no reason to bill these services unless you have reason to believe there is a secondary insurance that will pick it up (most won't). Also, please see my previous responses on this thread.
I suspect in your particular situation, it is an issue with Humana. You will need to get on their portal and look for their rules on the Gy/Gz modifiers as I suspect they do not recognize them. The Advantage plans are supposed to follow Medicare rules, but they have proven time and time again that they are rebels and go rogue! You can appeal with medicare documentation until you are blue in the face...they will usually just do what they want.
I always suggest that with these types of plans, know their quirks and work with them. If you have proof that an service gets denied billed a certain way, then that service should be cash pay for that payer going forward. Collect up front and bill if the patient requests it.