Ophthalmology and Optometry Coding Alert

This is no win-win situation, but this modifier helps you make the best of it

It happens to even the best-run ophthalmology practices--the ophthalmologist has just performed a noncovered service and there's no ABN on file.

If you should have had a patient sign an ABN but failed to do so, you should append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the noncovered service the physician provided.

You can also append modifier GZ when you provide an ABN and the patient elects not to pay for the service, but the physician decides to provide the service anyway. The patient will not be responsible should Medicare determine the claim is not payable.

"You don't want to be in the position to use modifier GZ because it means that you probably won't get paid," says Joyce Ludwick, compliance consultant with Park City Solutions Group in Ann Arbor, Mich. "However, by notifying Medicare using modifier GZ, you reduce the risk of allegations of fraud or abuse when filing claims that are not medically necessary."

Plan ahead: Don't allow yourself to resort to modifier GZ. Have a policy in place to collect ABNs and provide an NEMB when necessary.

For more information on modifier GZ, visit www.cms.hhs.gov/medlearn/modchtgz.pdf.