AlisonFaught
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Our clinic just received a letter from an insurance company (Wellcare) stating that they are going to recoup all the money they have paid on the prevnar 13 vaccine (90670) over the past 2 years and their reason is that we used modifier GA with that code. "Pmnt Reversal-processing error-pd a non-covered benefit. Per CMS, claim lines billed with GA, GY, GZ are not payable." We have always gotten an ABN signed for this vaccine because it is a once per lifetime benefit and often times the beneficiaries cannot recall if they've had it (or if it has been a year since their once/lifetime pneumonia 90732 vaccine). Were we incorrect to use the GA modifier with this vaccine per CMS guidelines? The only CMS guideline I can find is from 2011 and it states that the GA modifier must be used when physicians want to indicate that they expect Medicare to deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. Is there a newer guideline I don't know about?