Orthopedic Coding Alert

GA is now required by many Medicare payers to indicate ABN.

When your provider performs a service for a Medicare patient that the payer might not cover, you'll often need to obtain a signed advance beneficiary notice (ABN) in advance of the service.

Without the ABN, you will not have informed the patient of the potential non-payment; thus, you typically won't be able to charge the patient without that ABN.

In the past, some providers have neglected obtaining ABNs. Now, however, compliance concerns practically command providers to get ABNs if Medicare might not cover a service.

And most experts are recommending that providers take it one step further. The relatively new G modifiers for ABNs that Medicare introduced several years ago have been similarly ignored by some providers. While you might have gotten away with neglecting the G modifiers in the past, experts recommend you start using G modifiers whenever appropriate.

Why? "If we use the G modifiers on ABN-pertinent claims, we can continue to prove compliance with what Medicare tells us to do," explains Leslie Johnson, CPC, Coding Consultant in Flagler Beach, Florida.

Another expert who advises coders to get friendly with the G modifiers is Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC in Indianapolis, Indiana.

According to Dillon, "the GA modifier is actually required by payer policy. When appending the GA modifier, it informs Medicare that there is a 'waiver of liability on file,'" she says.

Per CMS: "The GA modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary."

There are similar rules for the other G modifiers on the books as well; check out a full rundown of ABNs and G modifiers at: https://www.cms.gov/RegulationsandGuidance/Guidance/Transmittals/downloads/R2148CP.pdf.

Keep G Modifiers Straight with this Info

As a quick refresher, take a look at the complete list of the G modifiers below. we've also included some instructions on how to use each modifier from Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida.

Modifiers:

• 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.  
• 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.
• 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.