Last Modified: 10/31/2024
Location: FL, PR, USVI
Business: Part A, Part B
If a provider or supplier expects that the service or item furnished to the beneficiary may be considered unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used to inform the beneficiary of his or her financial liability, appeal rights, and protections under the fee-for-service (FFS) Medicare program.
Providers and suppliers should use the appropriate modifier when submitting such claims to indicate whether they have or do not have an ABN signed by the beneficiary.
GA modifier
The GA modifier is defined as waiver of liability statement issued as required by payer policy.
• Use the GA modifier to report an ABN was provided to the beneficiary indicating the likelihood of denial of the service as being not reasonable and necessary under Medicare guidelines.
• Report when you issue a mandatory ABN for service as required and is on file.
• You do not need to submit a copy of the ABN, but one must be available upon request.
• The most common example of these situations would be services adjudicated under a Local Coverage Decision (LCD).
GX modifier
The GX modifier is defined as a notice of liability issued, voluntary under payer policy.
• Use the GX modifier to report a voluntary ABN was issued for a service that Medicare never covers because it is statutorily excluded or is not a Medicare benefit.
• Line items submitted as non-covered will be denied as beneficiary liable.
• The GX modifier can be used in combination with the GY modifier, when applicable.
GY modifier
The GY modifier is defined as an item or service statutorily excluded, does not meet the definition of any Medicare benefit.
• Use the GY modifier to report that Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit.
• Services provided under statutory exclusion from the Medicare Program; the claim would deny whether the modifier is present on the claim.
• It is not necessary to provide the patient with an ABN for these situations.
• Do not use on bundled procedures or on add-on codes.
• The GY modifier can be used in combination with the GX modifier, when applicable.
GZ modifier
The GZ modifier is defined as an item or service expected to be denied as not reasonable and necessary.
• Use the GZ modifier to report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued.
• Medicare will auto-deny services submitted with a GZ modifier. The denial message indicates the patient is not responsible for payment; deny provider liable.
• If you did not have an ABN signed by the beneficiary, use a GZ modifier to indicate you expect Medicare will deny a service as not reasonable and necessary.
Note: All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with modifier GA or modifier GZ.
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