Wiki Secondary payor and modifier GZ

[Bernadette10]

This patient had a screening DEXA bone density test. Primary insurance is Humana Medicare Replacement HMO, and secondary insurance is BCBS. The only diagnosis is the screening code Z13.820 with normal findings. Since Z13.820 isn't covered by Medicare, it's giving me an error and won't let me submit the charge. If I add modifier GZ, then will the secondary insurance pay? I don't understand why BCBS is secondary, but that's how the insurance is listed. Also, no ABN was signed.

 

[CBLENNIE]

BCBS could be secondary for a variety of reasons which are listed in a very easy to understand format on Medicare Secondary Payer (MSP) page I included the link for. Look for the section titled Common Situations of Primary vs. Secondary Payer Responsibility.

If you are concerned about whether or not the Humana Medicare Replacement HMO is primary over the BCBS plan I would encourage you to take a look at this information and make sure that each plan is correctly considered primary/secondary. It can be a huge mess when you've been submitting claims to a Medicare plan as primary and received payments and it is subsequently determined that the Medicare plan should've been secondary. There is a section of the page titled Responsibility of Providers Under MSP and you want to make sure you are doing your due diligence to follow these items.

If I was in your position, I would first verify which plan is primary and which is secondary because if the BCBS plan should actually be primary you may've solved your issue of the non-covered DX for Medicare Z13.820.

I'm not an expert on the use of GY & GZ modifiers for Medicare and how that might impact the processing of the claim by BCBS if they are in fact secondary. Maybe someone else can help you understand which of these modifiers should be submitted on the claim if the claim is being submitted to the Humana Medicare Replacement plan as primary.

 

[Cbaxter001]

Howdy!
ABN's are only for patients active under straight Medicare, and do not apply for Medicare Advantage plans. The HMO being primary vs secondary depends on the coverage for the plan. If it's your HMO plan it's likely primary. If it's your Spouse's insurance it's likely secondary.

For the other question - This is really a question for patient's who have straight Medicare because GZ modifier does not apply to Medicare advantage plans, regardless BCBS will not pay on claims that the primary (Medicare) denies for not meeting medical necessity.

Medicare Part B covers DEXA scans (bone mass measurement) once every 24 months for people who are at risk for osteoporosis AND meet one or more of the following conditions:

• A woman whose doctor determines, based on her medical history and other findings, that she is estrogen deficient and at risk for osteoporosis.
• A patient whose X-rays show possible osteoporosis, osteopenia, or vertebral fractures.
• A patient taking prednisone or steroid-type drugs, or who is planning to begin this treatment. Z79.51-2
• A patient diagnosed with primary hyperparathyroidism.
• A patient being monitored to see if their osteoporosis drug therapy is working. Z79.83

Medicare only covers DEXA if there is a risk factor - they will not cover just a screening Dexa without a pre existing factor. We have to adjust a handful of exams at our facility due to not meeting medical necessity.