Wiki GA-GY-GZ Modifiers

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LindaEV

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Is all this correct???

GZ - an ABN should have been signed, but wasn't. Medicare denies and you cannot bill patient

GY - a non-covered (excluded service) that you are submitting for a denial EOB only. (this non-covered can also be charged to patient and you do not have to send claim to medicare)

GA - you are doing a covered procedure for a non-covered DX you have to get an ABN and use the GA or you have to write it off. You can bill patient if service is denied.

Is it wrong to continually bill services to Medicare that we know will not be covered, without any type of Modifier? Say a certain office states they are too busy to deal with ABN, so they continually submit claims to MCR that are denied as not covered, or not medically necessary.(losing big time money!!)
and someone else says this can cause a red flag to MCR, maybe indication that we are not following or don't know guidelines. (any truth to that-the "red flag" part)

Thanks!
 
WPS Medicare has some great modifier educational sheets:
http://www.wpsmedicare.com/part_b/education/modifiers.shtml

One says the modifier isn't required (GY) and that the service will deny anyway, GZ looks like an informational modifier only. I'm not sure about "red flags" to Medicare but it sounds like there is lots of potential revenue loss by not obtaining an ABN and using the modifier so you can bill the patient when they are responsible.

Maybe it would help if someone knew just how much money was being lost? Though sometimes it is hard to be "just" the coder or biller and have any say in things like that...
Good luck.
 
do not forget about GX effective oct 1 2010! this is when you obtain an ABN for noncovered services. What I read, and now I am looking to see if I can get that notice to come up again, is that after an edcational period following April 1 2010, IF you submit a GA modifier for a covered service with a cover dx then the service will auto deferr to patient responsibility, and if you use the GX on a covered procedure the claim will deny for invalid modifer. Hmmmmmmmm
 
So, has anyone found a way around this? Your sort of damed if you do, and damed if you don't. We're having a hard time finding info on GX. Anyone
else having similar problems? All our dexas are being denied with the GA modifier.
Thanks.
 
733.90, 733.01,733.00 AND V49.81, pretty much everything that
previously was covered. All had a signed ABN, and I used a GA modifier.
Thanks!
 
were the dexas for screening or because the patient is on drug therapy? and V49.81 is secondary only allowed. It could be the dx is not the correct medical necessity.
 
It seems as though they are not even looking at the dx, just the fact that
there is a GA modifier is the reason not to pay. All of the dxs that I previously
mentioned always covered the dexa before April 1st. There is some discussion
to not use the modifier if the ABN has been signed, but I'm of the mind that that's probably not legal. Also, the GX code is not recognized by some of our software, and I'm wondering if thats because it doesn't go into effect until October?
 
You are correct in that you must use a modifier if you have a signed ABN, also The info I have shows the GX went into effect April1,
But the same memo did say that the presence of the GA modifer would automatically default the line item to patient responsibility, could it be that they were not kidding? I honestly did not believe that would really happen.
 
GX Modifier

The info I have is from an excel file downloaded from CMS. I don't know where the link is to now, but I looked into the file I have and it says that the GX is a voluntary liability notice: NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY, Coverage C, effective 4-1-2010.

I also have this on the same excel sheet: GA Required liability notice WAIVER OF LIABILITY STATEMENT ISSUED, AS REQUIRED BY PAYER POLICY Coverage C 4/1/2010


Hope it helps
 
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Abn

So, is the solution not generating an ABN for dexas? If you have a signed ABN, the patient pays. If you don't have an ABN at all, there is a chance
that it will get paid, but if it doesn't, we pay? I find this all very confusing!
Someone else must be having this problem.
 
the issue here stems from about 2 years ago when the OIG isssued a statement that they were very "concerned" about the overutilization of ABNs. Honestly from my observations I think they were correct. What they are doing now does force you to know when an LCD or NCD has been met by the dx or you need to know when an item is covered or non covered. Good idea???? maybe!
 
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