Wiki Abn modifiers

[wfriddle]

Has anyone used ABN's for Medicare Well Women visits if the patient is wanting to come in annually rather then bi-annually? If so which modifier do I use? They are a little confusing to me.
The GA modifier states to use "when you issue a mandatory ABN for a services as required..."
How do I know if it is mandatory or voluntary?

 

[teresabug]

If there is the possibility that MCR wont pay the claim have the pt sign the ABN form which gives you the right to bill the patient for the service. There are 2 different ABN modifiers btw. One saying you know for sure MCR will deny then you can bill the 2ndary ins for payment and the other gives you the right to bill the patient regardless. You cant bill the pt unless its signed either way.

 

[dclark7]

There are 4 different modifiers to add to services, GA, GX, GY and GZ. GZ will always deny with the responsibility to the provider. It basically means that you knew the services were not covered but did not get an ABN. GY would be used if the item is never covered by Medicare (statutorily excluded) for example a routine physical (CPT codes 99381-99397), in this case no ABN is necessary since it is not a contract benefit. Modifier GX would be used if an item is not a contract benefit but you obtained an ABN anyway. Finally modifier GA is used when you think Medicare may not cover a service because it exceeds quantity limitations, the diagnosis isn't covered for that service (LCD limitation) or the patient is requesting a service that may not be considered medically necessary. In your example their request would exceed Medicare's service limitations so you should use the GA modifier if the patient signs an ABN.

Be aware that use of the GA, GX and GY modifiers should automatically cause a denial of the claim with the responsibility to the patient (PR). The patient can appeal if they want to. Use of GZ will cause an automatic denial with responsibility to the provider, no appeal rights (CO).

CMS has a lot of information if you go to their website (CMS.gov) and type ABN in the search bar.

 

[wfriddle]

Thank you so much, that is exactly what I was needing to know. I found the modifiers and their discriptions on CMS but just needed a little more clarification.

 

[Chlrtrep]

Be aware that use of the GA, GX and GY modifiers should automatically cause a denial of the claim with the responsibility to the patient (PR). The patient can appeal if they want to. Use of GZ will cause an automatic denial with responsibility to the provider, no appeal rights (CO).

CMS has a lot of information if you go to their website (CMS.gov) and type ABN in the search bar.

I realize this is an older post but we had a recent procedure that required the use of the GZ modifier to CPT 0238T. the physician also performed in addition to the atherectomy of an iliac artery he performed an iliac angioplasty and LHC Cath and PCI with DES placement to two coronary arteries. Because there was no ABN signed and the physician felt he required to perform the atherectomy of the iliac out of medical necessity were instructed to add the GZ modifier to the procedure code 0238t. We have been informed this patient's entire claim has been denied. I was wondering is some one can help explained why the whole claim is denied and just not the line with the 0238t service. I have reviewed what was listed on the WPS website (our local MAC and on CMS). My interpretation is that only the services with the G-modifier should be denied. This is the information I read. How am have I misunderstood their policy.

WPS GHA

Tags: J8A,J5A,J8B,J5B
Information about modifier GZ.
This content applies to the following jurisdictions:
Definition: The provider or supplier expects a medical necessity denial, however, did not provide an Advance Beneficiary Notice of Non-coverage (ABN) to the patient.
Facts
• This modifier is an informational modifier only.
• Medicare will adjudicate the service just like any other claim.
• If Medicare determines that the service is not payable, denial is under a "medical necessity." The denial message will indicate that the patient is not responsible for payment.
• If either the beneficiary or provider requests a review, the modifier tells us that an ABN was not given, and this could help in completing the review quickly.
• Medicare will auto-deny services submitted with a GZ modifier. The denial message will indicate that the patient is not responsible for payment.
• If either the beneficiary or provider requests a review, the modifier tells us that an ABN was not given.

CMS
F. GZ Modifier
Effective for dates of service on and after July 1, 2011, contractors shall automatically deny claim line(s) items submitted with a GZ modifier. Contractors shall not perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make all language published in educational outreach materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. When claim line(s) items submitted with the Modifier GZ are denied, contractors shall use the following codes: Group Code CO (Provider/Supplier liable) and CARC 50 defined “These services are non-covered services because this is not deemed a ‘medical necessity’ by the payer.