Ophthalmology and Optometry Coding Alert

Question: Should I use modifier -GA when my ophthalmologist is performing ocular photodynamic therapy (OPT) for patients with age-related macular degeneration?

OPC Subscriber Answer: The answer to your question can be found in a recent program transmittal released Aug. 20 by the Centers for Medicare and Medicaid Services. Transmittal 157 states, "Providers must use the -GA modifier (Waiver of liability statement on file) when billing for OPT with verteporfin for patients with a diagnosis of AMD with occult and no classic CNV lesions where the beneficiary has signed an advance beneficiary notice (ABN)."

The transmittal also outlines the use of modifier -GZ (Item or service expected to be denied as not reasonable and necessary) when billing for OPT with verteporfin for patients with a diagnosis of AMD with occult and no classic CNV lesions where the beneficiary has NOT signed an ABN. According to CMS, "such claims must be denied by the contractor because the service is noncovered due to the national coverage determination."

Because this revision to the Coverage Issues Manual is a national coverage decision (NCD), all Medicare carriers, intermediaries, peer review organizations, health maintenance organizations, competitive medical plans, and healthcare prepayment plans are required to comply by these regulations.