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ABN Modifiers More Specific in 2010

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  • November 16, 2009
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To ensure proper reimbursement, billing staff will need to update their standard knowledge of Advance Beneficiary Notice (ABN) modifiers. A Medicare policy revision due to take effect in 2010 changes modifier usage when reporting certain types of liability notices for non-covered services to a Medicare payer.

Effective April 1, 2010, two HCPCS Level II modifiers should be used to distinguish between voluntary and required uses of liability notices.

Modifier GA Waiver of liability statement issued as required by payer policy has been redefined and should be used to report when a required ABN was issued for a service. This modifier should not be reported in association with any other liability-related modifier and should continue to be submitted with covered charges.

Modifier GX Notice of liability issued, voluntary under payer policy is new and should be used to report when a voluntary ABN was issued for a service. You may report this modifier on the same line as the other liability-related modifiers: GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit; and TS Follow-up service.

Do not report modifier GX on the same line as liability-related modifiers: EY No doctor’s order on file; GA; GL Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN; GZ Item or service expected to be denied as not reasonable and necessary; KB Beneficiary requested upgrade for ABN, more than four modifiers identified on claim; QL Patient pronounced dead after ambulance is called; or TQ Basic life support transport by a volunteer ambulance provider.

Medicare systems will automatically deny lines (using claim adjustment reason code 50) submitted with the GA or GX modifier and non-covered charges, and will assign patient liability to claims automatically denied when either modifier is present.

These changes to the Medicare Claims Processing Manual, chapter 1, section 60 were announced Oct. 29 by the Centers for Medicare & Medicaid Services (CMS) in Transmittal 1840, Change Request 6563 and MLN Matters MM6563.

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    ABN Modifiers