Medicare and J7307


Columbus, Ohio
Best answers
Hello, I keep getting a denial from Medicare for hcpcs J7307(Nexplanon) stating that the procedure code was invalid on the date of service. I know this is not covered by Medicare but until I get a Pt Responsibility non-covered denial, I cannot forward to Medicaid. I called Medicare and they said that this code is not valid for them and there is another code that I should be using but they would not tell me what it was and I cannot find anything else. Any help with this would be very much appreciated. Thank you!


Largo, FL
Best answers

Since this is a non covered item with Medicare did you apply the correct modifier

Medicare ABN Specific Modifiers – GA, GX, GY, GZ

When submitting charges to Medicare.* How*to indicate whether or not an ABN (Advanced Beneficiary Notice) was given to the patient.*

These are the top 4 Medicare modifiers we use.

GA Modifier:
Waiver of Liability Statement Issued as Required by Payer Policy.
This modifier indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare.
Use of this modifier ensures that upon denial, Medicare will
automatically assign the beneficiary liability.

GX Modifier:
Notice of Liability Issued, Voluntary Under Payer Policy.
Report this modifier only to indicate that a voluntary ABN was issued for services that are not covered.
Medicare will automatically reject claims that have the –GX modifier applied to any covered charges.
Modifier –GX can be combined with modifiers –GY and –TS (follow up service) but will be rejected if submitted with the following modifiers: EY, GA, GL, GZ, KB, QL, TQ.
Additional information on the –GX modifier can be found at:*

GY Modifier:
Notice of Liability Not Issued, Not Required Under Payer Policy.* This modifier is used to obtain a denial on a non-covered service.* Use this modifier to notify Medicare that you know this service is excluded.

GZ Modifier:
Item or Service Expected to Be Denied as Not Reasonable and Necessary.* This modifier should be applied when an ABN may be required, but was not obtained.