American College of Physicians: Internal Medicine — Doctors for Adults ®

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Providing uncovered services? Use these modifiers

From the May ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

How ACP-ASIM helped reduce the hassle factor of modifiers

Q: What modifiers can I use on claims for services that Medicare may not cover, and how do I use them?

A: In March of this year, the Centers for Medicare and Medicaid Services (CMS) introduced two new modifiers to include on claims for services that Medicare may not cover. The two modifiers—and an existing code—are described below.

  • GY modifier. You can use this modifier to indicate that you are submitting a claim for a service that you know Medicare excludes from coverage by law. Append the modifier to the code, for example, to bill for a periodic preventive examination that you provide to a patient who has no sign, symptom, illness or injury.

    You may submit the claim for a noncovered service that a beneficiary insists on receiving, or to facilitate a denial so the claim can be forwarded to a secondary payer. Using this modifier will speed Medicare's decision to deny the claim. Once you receive a denial notice, you can bill the beneficiary your usual charge.

    Your patient does not have to sign an advance beneficiary notice (ABN) because beneficiaries are expected to know which services Medicare does not cover by law.

  • GZ modifier. You can use this modifier when you expect a service to be denied because it fails to meet Medicare's "reasonable and necessary" criteria and the patient has not signed an ABN form. If a patient has a specimen tested without first coming to your office, for example, use this modifier when you bill for the service to indicate that you know the patient should have signed an ABN form.

    If Medicare denies payment and the patient has not signed an ABN, you generally cannot bill the patient for services. CMS has said that using the GZ modifier, however, removes any suspicion that you routinely bill for services that fail to meet Medicare's "reasonable and necessary" criteria.

  • GA modifier. Use the existing GA modifier when you expect a service to be denied because it fails to meet Medicare "reasonable and necessary" criteria and the patient has signed an ABN form.

    Physicians typically ask beneficiaries to sign an ABN form when a service is eligible for Medicare coverage but may be denied under certain circumstances. You might ask beneficiaries to sign an ABN, for example, if you think that Medicare may determine that a laboratory test is being provided too frequently.

    Medicare will not automatically deny a claim with a GA modifier, and using the modifier is irrelevant if Medicare decides to pay the claim. If Medicare denies a service submitted with the modifier, however, the patient must pay you for the service (or use a secondary insurer).

Charts illustrating CMS' policy on these modifiers are online at www.hcfa.gov/medlearn/refabn.htm. Scroll down to "exhibits" and click on the link to each modifier.

Brett Baker is a third-party payment specialist in the College's Washington office.

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How ACP-ASIM helped reduce the hassle factor of modifiers

ACP-ASIM's efforts helped make the above modifiers less burdensome for physicians.

When CMS first proposed the modifiers in April 2001, ACP-ASIM and other medical organizations complained that physicians were being asked to provide too much information with their claims. CMS scaled back the policy, but the College continued to express concerns that the new modifiers would be too burdensome to physicians.

As a result, CMS agreed to ACP-ASIM's recommendation that the modifiers be made voluntary. The College has also urged CMS to make sure that carriers notify beneficiaries when they are responsible for paying for services that are not covered by Medicare.

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