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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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ABN Modifiers 

GA Modifier

Waiver of Liability Statement Issued as Required by Payer Policy.

    • This modifier indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare.
    • Medicare systems will automatically deny lines submitted with the -GA modifier and covered charges on institutional claims;
    • Medicare systems will assign beneficiary liability to claims automatically denied when the –GA modifier is present; and
    • Medicare will use claim adjustment reason code 50 (These are noncovered services because this is not deemed a ‘medical necessity’ by the payer.) when denying lines due to the presence of the –GA modifier.

GX Modifier

Notice of Liability Issued, Voluntary Under Payer Policy.

    • Medicare systems will recognize and allow the –GX modifier on claims, but will return your claim if the –GX modifier is used on any line reporting covered charges;
    • Medicare systems will allow the –GX modifier to be reported on the same line as the following modifiers that indicator beneficiary liability: -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit), -TS (Follow-up service);
    • Medicare systems will return your claim if the –GX modifier is reported on the same line as any of the following liability-related modifiers: -EY (no doctor's order on file), -GA, -GL (medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN), -GZ (item or service expected to be denied as not reasonable and necessary), -KB (Beneficiary requested upgrade for ABN, more than four modifiers identified on claim), -QL (Patient pronounced dead after ambulance is called), -TQ (basic life support transport by a volunteer ambulance provider);
    • Medicare systems will automatically deny lines (using claim adjustment reason code 50) submitted with the -GX modifier and non-covered charges, and will assign beneficiary liability to claims automatically denied when the –GX modifier is present.

GY Modifier

Notice of Liability Not Issued, Not Required Under Payer Policy.  This modifier is used to obtain a denial on a non-covered service.  Use this modifier to notify Medicare that you know this service is excluded.

GZ Modifier

Item or Service Expected to Be Denied as Not Reasonable and Necessary.  This modifier should be applied when an ABN may be required but was not obtained.

Reference

MLN Matters Number: MM7821

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