Waive Liability Goodbye With -GA
Published on Sun Sep 01, 2002
Learn the rules of the altered -GA modifier (Waiver of liability statement on file) and the new HCPCS modifiers -GY and -GZ or you could end up footing the bill for the next cosmetic blepharoplasty you perform. A blepharoplasty, 15820-15823, is just one of the many ophthalmological services that might be classified and denied as "not reasonable or necessary" according to Medicare, thereby necessitating the use of modifier -GA when a signed advance beneficiary notice is obtained. The premise that the beneficiary signed an ABN is a crucial element when identifying codes that require modifier -GA. The new advance beneficiary notices introduced by Medicare effective July 1 are part of CMS' beneficiary notices initiative (BNI). While the revised ABNs serve the same function of advising beneficiaries about receiving items that they may have to pay for themselves, the new ABNs are an attempt to define patient options more clearly and to be more reader-friendly for beneficiaries. For example, a patient presents with excessive skin of the right eyelid but it does not cause impaired vision or fit the criteria of medical necessity established by the carrier local medical review policies. The ophthalmologist decides that the procedure is not medically necessary and is therefore cosmetic. The patient is then presented with an advance beneficiary notice, which he signs. The physician performs a blepharoplasty of the extra upper eyelid skin, 15822 (Blepharoplasty, upper eyelid). This procedure should now be billed 15822-GA-RT. The -GA modifier should also be applied to visual field tests that correspond to diagnosis codes that are not covered. For example, if a fluorescein angiogram code (92235) is paired with a blurred vision diagnosis code such as 368.8, a code that does not constitute medical necessity according to most LMRPs, modifier -GA should be appended. According to CMS, -GA may also be used when assigned and unassigned claims for DMEPOS fall under certain Part B "technical denials" prohibited telephone solicitation, no supplier number, and failure to obtain an advance determination of coverage. CMS provides three scenarios that require the use of modifier -GA:
When you think a service will be denied because it does not meet the Medicare program standards for medically necessary care and you gave the beneficiary an ABN Anytime you obtain a signed ABN or have a patient's refusal to sign an ABN witnessed properly in an assigned-claim situation (with the exception of an assigned claim for one of the specified DMEPOS technical denials)
On an assigned claim if you gave an ABN to a patient but the patient refused to sign it and you did furnish the services.
Other instances in which -GA might be used include "many [...]
