• Modifier GZ must be used when providers, physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an advance benefi ciary notifi cation (ABN) signed by the benefi ciary.
• Modifier GA must be used when providers, physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on fi le an ABN signed by the beneficiary.
• All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with modifi er GA or GZ.
How to use ABN Modifiers?
Modifiers GA and GX were created to differentiate between mandatory and voluntary ABNs. Modifier GA has been redefined as “waiver of liability statement issued as required by payer policy” and should be used when a mandatory ABN was issued to a beneficiary. Billing staff should not report Modifier GA with any other liability-related modifier such as GZ (item or service expected to be denied as not reasonable and necessary); EY (no doctor’s order on file); GL (medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN); GX (notice of liability issued, voluntary under payer
Although, it is voluntary to provide an ABN for items or services that are statutorily excluded or lack a Medicare benefit category, a facility’s conditions of participation may require the provider to inform the beneficiary of non-coverage.
Moda Health Commercial plans:
Modifiers GA, GX, GY, and GZ are considered valid for commercial lines of business. We are prepared to process Medicare supplement claims that may have been submitted to Original Medicare with these modifiers.
In addition, non-covered screening procedure codes submitted with a screening diagnosis code and modifier GA or GX appended will deny to member liability. Modifiers GY and GZ have no effect on this process. Please refer to Moda Health Reimbursement Policy # RPM037 “Preventive Services versus Diagnostic and/or Medical Services” for complete information.
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