Clear The Confusion About Medicare GA, GX, GY, GZ Modifiers

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Clear The Confusion About Medicare GA, GX,
GY, GZ Modifiers
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Clear The Confusion About Medicare GA, GX, GY, GZ
Modifiers

• Healthcare providers often get confused about the
  appropriate use of modifiers GA, GX, GY, and GZ
  while billing Medicare. In this article, we
  shared detailed information on GA, GX, GY, and GZ
  modifiers, their description, when to use them,
  the difference between services that are
  statutorily excluded and services that are not
  necessary, what to do when you gather ABN, and
  which modifiers are allowed to bundle together.
• GA Modifier Waiver of Liability Statement Issued
  as Required by Payer Policy
• You can use GA modifier when you think a service
  will be denied because it does not meet the
  Medicare program standards for medically
  necessary care and you gave the beneficiary an
  advance beneficiary notice. GA modifier indicates
  that an Advance Beneficiary Notice (ABN) is on
  file and allows the provider to bill the patient
  if not covered by Medicare. Use of this modifier
  ensures that upon denial, Medicare will
  automatically assign the beneficiary liability.
  Use a GA modifier on an assigned claim if you
  gave an ABN to a patient but the patient refused
  to sign the ABN and you did furnish the services.
  The GA modifier also may be used with assigned
  and unassigned claims for DMEPOS where one of the
  following Part B technical denials may apply
• Prohibited telephone solicitation,
• No supplier number,
• Failure to obtain an advance determination of
  coverage.

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Clear The Confusion About Medicare GA, GX, GY, GZ
Modifiers
GX Modifier Notice of Liability Issued,
Voluntary under Payer Policy. Report GX modifier
only to indicate that a voluntary ABN was issued
for services that are not covered. Medicare will
automatically reject claims that have the GX
modifier applied to any covered charges. Modifier
GX can be combined with modifiers GY and TS
(follow up service) but will be rejected if
submitted with the following modifiers EY, GA,
GL, GZ, KB, QL, and TQ. GY Modifier Service
provided is Statutorily Excluded from the
Medicare Program The Center for Medicare
Medicaid Services (CMS) created two modifiers
that allows to distinguish between services that
are statutorily excluded, or otherwise not a
Medicare benefit because Medicare does not
consider them reasonable and necessary.
Statutorily excluded refers to Medicare benefits
that are never covered according to law.
Statutory refers to written law. Medicare does
not pay for all health care costs. Certain items
or services are program or statutory exclusions
and will not be reimbursed by Medicare under any
circumstances. Adding the GY modifier to the CPT
code indicates that an item or service is
statutorily excluded or the service does not meet
the definition of Medicare benefit. This will
automatically create a denial and the beneficiary
may be liable for all charges whether personally
or through other insurance.
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Clear The Confusion About Medicare GA, GX, GY, GZ
Modifiers
Note that the claim will deny whether or not the
modifier is present on the claim. For example,
when a beneficiary wants new eyeglasses and wants
to get a denial through Medicare for secondary
payer purpose, the claim should be submitted with
GY modifier. This way the claim may be processed
faster than it would be without GY modifier.
Advanced Beneficiary Notices (ABNs) are not
acceptable for statutory exclusions. Note that
HCPCS modifier GY cant be used on bundled
procedures or on add-on codes. Modifier GZ Item
or Service Expected to be denied as Not
Reasonable and Necessary Medically necessary
services are defined as health care services or
supplies that are needed to diagnose or treat an
illness, injury, condition, disease or its
symptoms, and that meet accepted standards of
medicine. If the services billed do not meet the
criteria, then it is not considered reasonable
and necessary. Medicare will auto-deny services
submitted with a GZ modifier. The denial message
indicates that the patient is not responsible for
payment deny provider liable. Use this modifier
to report when you expect that Medicare will deny
payment of the item or service due to a lack of
medical necessity and no ABN was issued. Use when
the provider expects denial due to a lack of
medical necessity based on an informed knowledge
of Medicare policy. Medicare will automatically
deny claim line(s) items submitted with modifier
GZ, using Claim Adjustment Reason Code CO-50.
(i.e., these services are non-covered services
because this is not deemed a medical necessity
by the payer.) Do not submit both modifier GZ and
modifier GA/ GY on the same claim line.
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Clear The Confusion About Medicare GA, GX, GY, GZ
Modifiers
Do not add the GZ modifier to a corrected claim
if you are correcting a charge and putting it as
non-covered. This causes the line to deny
because lines with the GZ modifier are
automatically denied. Medicare will adjudicate
the service just like any other claim. The denial
message will indicate that the patient is not
responsible for payment. If either the
beneficiary or provider requests a
redetermination, the modifier indicated that an
ABN was not given, and this could aide in
completing the review quickly. Medisys Data
Solutions is a leading medical billing company
providing complete billing and coding services
for various medical billing specialties. We hope
that this article might help you to clear the
confusion about appropriately using GA, GX, GY
and GZ modifiers while billing Medicare. If you
are seeking assistance while billing Medicare,
contact us at info_at_medisysdata.com / 888-720-8884
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Clear The Confusion About Medicare GA, GX, GY, GZ
Modifiers
Modifier QX Qualified Non-Physician Anesthetist
Service (with Medical Direction by a
Physician) Modifier QX is used by a nurse
anesthetist or anesthesiologist assistant when
medically directed by a physician
anesthesiologist. In such a case, as discussed
above, a physician anesthesiologist would submit
a corresponding claim for medical direction,
either with modifier QK or modifier QY.Payment
for this service is split between the two
anesthesia professionals with 50 percent of the
allowed amount paid to the anesthesiologist and
50 percent to the nurse anesthetist or
anesthesiologist assistant. To cross-check check
billing accuracy of anesthesia services, a claim
submitted with the modifier QX should match a
claim submitted with the modifier AD. Modifier
QZ Certified Registered Nurse Anesthetist (CRNA)
Service (without Medical Direction by a
Physician) This modifier is specific to certified
registered nurse anesthetists and should not be
reported by anesthesiologist assistants. In this
scenario, a nurse anesthetist provides care under
the supervision of or via a collaborative
arrangement with the surgeon of other mode as
permitted by state law medical direction by a
physician anesthesiologist is not present. The
nurse anesthetist receives 100 percent of the
allowed amount for cases reported with the QZ
modifier. Medisys Data Solutions is a leading
medical billing company providing complete
billing and coding services for various medical
billing specialties. We hope that our article on
anesthesia modifiers will guide you in accurately
billing for anesthesia services. If you are
seeking assistance in anesthesiology billing and
coding for your practice, contact us at
info_at_medisysdata.com / 888-720-8884
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