Wiki Modifier -GZ for Medicare and MedAdvantage plans

campt

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I keep getting CO-4 denials when a code is billed to MCR/MCR Advantage with modifier -GZ. From what I've seen, all CPT codes billed to MCR/MCR Advantage with -GZ are being denied as missing a modifier or that the wrong modifier was used. In reality they should be denied as not medically necessary, correct? (the client does put the charges under Non-Covered on a UB)

If anyone has insight on this issue, please let me know. Thanks!
 
What codes are you billing with this modifier?

Normally a medical necessity denial is CO-50 is there is no ABN, or PR-50 if there is an ABN. But this only applies to services for which an LCD or NCD is in place. The ABN process does not apply to other services, for example those that are statutorily non-covered, so it's possible you're getting this denial on codes that would never be expected to have an ABN associated with them.
 
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