Effective April 1, 2010 CMS is implementing the GX modifier. With the addition of the GX modifier, all claims for hospitals/facilities with GA modifier on them will deny as patient responsibility without going through Medicare's processing, specifically a medical necessity check.

Is anyone else's facilities effected by this change?

Here is my situation: Our lab system does a check against Medicare LCD and NCDs to determine medical necessity as well as frequency restrictions. Because there are some labs which have a frequency restriction (PSA, Pap, TSH, Glucose, etc) and we have no way of verifying the last time the test was performed, we are having the patient sign an ABN.

Currently this test would go to Medicare and they would verify the frequency of this test against the last time the patient had it done. After 4/1/10 the labs will deny automatically regardless if the patient is outside the frequency restriction. Talk about a PR nightmare.

This doesn't only apply to labs, but any services that we get an ABN for that might still get paid but we are unsure of the medical necessity of the dx or the frequency.

Any thoughts? Any advice? We have contacted Noridian and they were unable to provide any guidance, apparently they haven't received any other calls about this same concern.

Please let me know if you are in the same situation and what you plan to do about it. I would be happy to communicate via email or phone, just send me a private message.