EM Coding Alert

Medicare uses G modifiers to specify why practice issues ABN.

Patients that report to your physician for evaluation and management (E/M) services that Medicare might not completely cover should always be on your advance beneficiary notice (ABN) radar.

Once you’ve provided the patient with the ABN, Medicare also asks that you append the proper G modifier. While the G modifiers are not required to garner pay for the services, experts think it’s a good idea to use the modifiers for compliance reasons. G modifiers also make things easier on payers, as they indicate whether you will be able to request payment from the patient.

Check out this rundown of the G modifiers you might use on your ABN claims.

Mark Mandatory ABN Issuance With GA

Here’s a list of the G modifiers you’ll choose from for ABN services, along with some analysis from Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD,  a coding, billing, and practice management consultant in central Florida:

• 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,” Verno explains. You don’t need to submit the ABN on GA claims, but you should have it available upon request, Verno says.
• 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,” says Verno. In certain situations, you can also use this modifier in combination with modifier GY (see below).
• 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 excludes the item or service; or the item or service does not meet the definition of any Medicare benefit,” explains Verno. In certain situations, you can also use this modifier in combination with modifier GX. This modifier is often necessary to determine secondary insurancepayments.
• 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,” says Verno.

Use G Modifiers to Stay in Coding ‘Mainstream’

While the G modifiers won’t impact Medicare’s payment for the service, it might use the information to look into billing patterns at your practice, explains Leslie Johnson, CPC, CSFAC, chief coding officer at PRN Advisors in Palm Coast, Fla.

Explanation: Medicare tracks every single code and modifier that you report. “Codes that are reported — or not reported — are indicative of patterns that are tracked by the data-mining systems. Deviate from the norm one way or another, and this could attract unwanted attention” from Medicare, Johnson warns.

Best bet: Reduce the risk of being a coding outlier by submitting G modifiers whenever you report a service for which you have an ABN on file.