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Commonly Used Medicare Modifiers – GA, GX, GY, GZ

Health Insurance Companies Process 1 in 5 Claims Wrong

Medicare ABN Specific Modifiers – GA, GX, GY, GZ

Medicare-ABN-GA-GX-GZ-GY-ModifiersWe get a lot of questions at our medical billing company about which modifiers to use when submitting charges to Medicare. Specifically, we are often asked how to indicate whether or not an ABN (Advanced Beneficiary Notice) was given to the patient.  These are the top 4 Medicare modifiers we use.

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.
  • Use of this modifier ensures that upon denial, Medicare will
    automatically assign the beneficiary liability.

GX Modifier:

Notice of Liability Issued, Voluntary Under Payer Policy.

  • Report this 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, TQ.
  • Additional information on the –GX modifier can be found at:  http://www.cms.gov/mlnmattersarticles/downloads/MM6563.pdf

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.

Additional information can be found at: http://www.cms.gov/manuals/downloads/clm104c12.pdf

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is a 20 year veteran of healthcare having managed medical practices. He advises medical practices, physicians and practice administrators on how to run their practice and manage their medical billing and revenue cycle management. Manny speaks, blogs and makes videos at www.CaptureBilling.com, a blog that is tops in the medical billing and coding field. READ MORE

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36 Responses to Commonly Used Medicare Modifiers – GA, GX, GY, GZ

  1. According to my boss, yes they do. But she also mentioned something regarding an appeal that she did submit to CMS and they denied it. Can you please explain to me in layman terms what actually is the PQRS? I know what it stands for, but I do not understand what it is suppose to do. If she is enrolled in it then she shouldn’t get penalized for it correct? I believe that whomever enrolled her in it didn’t do it correctly. Is there a way to find out?

  2. I was wondering if you could possibly help with an issue…I do all the billing for a doctor out of our System, she Does use a EMR system, and does prescribe, just not bill out of it (because we do on our end), Medicare is taking out the sequestration, plus an addition tax, due to her not billing out of her system. Is there a code to report to show this? Any information will be greatly appreciated.

    • Hi Melinda —

      Depending on the practice, for sequestration, we either increase the write-off by the sequestration amount or have a code, similar to a write-off code, indicating sequestration W/O.

      As far as an additional tax for not billing out of the doctor’s billing system, I am not familiar with that. Do you have more info you can share?

      • It comes up on the Medicare EOB as “CO-237, Legislated/Regulatory penalty” along with the “CO-253 Sequestration”

        I was told by my boss that it was due to the doctor doesn’t send the claim directly on her end.

        Thank you for your input.

          • Okay sorry to keep bugging you, but I’ve read all this before and I’m still a bit confused, what codes? Is this something that I would report for her, or she would have to do it? I understand that it is “quality control” but to what and how? Thank you again.

  3. Hello
    I am trying to bill L0120 and L0174 to UHC.

    Only one is getting paid, what modifier should I use to get both paid. UHC is the only plan that I have trouble with

    • Bridgitte you are going to have to talk to UHC to see what their rules are for these codes. They might be considering them similar items since they are both cervical collars and thus not covering one. You know how UHC likes not to pay.

  4. I want to know if I am billing the claim correctly for upgraded items.
    And yes we have ABN on file.

    A7031-NU-GA 26.27 ($$$$ pt will pay)
    A7031-NU-GK 107.23 ($$$$ medicare will pay)

    • We don’t bill for CPAP supplies but I did find some information that may be helpful.

      “GK Reasonable and necessary item ordered when a piece of equipment has been upgraded.

      When billing for upgrades, suppliers must use two lines on the same claim. Line one contains the HCPCS code for the upgraded item the supplier actually provided to the beneficiary with the dollar amount of the upgraded item. If an ABN was obtained, the GA must be billed. If an ABN was not obtained, use the GZ modifier. Line two is billed with the HCPCS code for the reasonable and necessary item with modifier GK and for the full amount of that item.

      Suppliers must also list the upgrade features in Item 19 of the CMS-1500 form or the electronic equivalent.

      GL Item is a medically unnecessary upgrade provided instead of a standard item at no charge to the beneficiary and an ABN does not apply.

      If a supplier furnishes an upgraded DMEPOS item but charges Medicare and the beneficiary for the non-upgraded item, the supplier must bill for the non-upgraded item rather than the item the supplier actually furnished. The claim is billed with the HCPCS code for the non-upgraded item with the charge of that item and modifier GL.

      Item 19 of the CMS-1500 form, or the electronic equivalent, must contain the make and model of the item actually furnished and describe why it is an upgrade.”

  5. I have a question on the correct modifiers to use in the following instance. We are a DME provider. We have a customer that wants a lift chair which is a face to face item. We have notes from the doctor but they are about a week past the 6 month prior to DOS requirement. In the notes there is only mention of Osteoarthritis and the CMN has a DX of osteoarthritis. For these reasons we had the patient sign an ABN. I was wondering what modifiers we would use to show that we have the notes and we expect it to be denied and have a signed ABN?

  6. On November 1, 2015 Medicare no longer allows the GA and AT modifiers to be used together. Do you have any ideas about how to bill a service as acute and let them know that we have an ABN on file? When talking with Medicare reps, they don’t have a clue.

  7. Hi Manny,
    I am trying to find out if GA is the correct modifier that we would use for hearing aids since Medicare doesn’t cover those services at all?
    Thanks, Michelle

  8. Hello, I work at a hospital and we are having difficulty understanding which modifier(s) to use on physical therapy services. Our physical therapy department indicates that the services do not meet medical necessity. An ABN was issued. We billed with Occur code 32 and GA modifier on the claim, and Medicare paid (perhaps because of the physician’s diagnosis). We have contacted Medicare and still unclear as to what modifier(s) to use. The ABN option #1 was chosen by the patient, wanting us to bill Medicare for services. Should we use GA, or GX, or both? Thanks

      • Perhaps it would be helpful to know that the therapist states the patient does not meet med necessity for services provided by a skiled therapist. In other words they could have it done at a gym, ymca, at their home.

  9. Hi Manny,

    How can I get the correct PR denial from Medicare for patients that are in LTC to bill the secondary? What modifiers are needed for DME Wheelchairs such as E1161’s?

  10. Hi Manny,

    We’re needing some clarification on when it’s okay to add a GY modifier. We have a member that doesn’t meet the criteria to get a Lymphadema Pump due to the diagnosis were using yet the doctor wants him to use one. His sec will pay if we get the denial code of PR-204 non covered. The secondary ins will not pay with if we get denial reasons PR-50 & PR-96. If we bill with a GY modifier we’ll we get the appropriate denial code PR-204, but in this case is it okay to bill with a GY modifier when Medicare will cover this item if the member meets the criteria? Do we have to get an ABN on file when we use GY modifier? If we have an ABN on file do we have to bill with Modifier GA? When we add GA modifier we get denied with PR-50 or PR-96. How can we get the appropriate denial of PR-204 that the secondary insurance is asking for? Your help in this matter is greatly appreciated!

  11. Hi Manny,
    I need to produce a denial from Medicare showing PR, patient responsibility instead of CO, contractual obligation. If I attach the GY modifier, will this cause a PR denial for me to forward to their secondary? Any help will be appreciated.

  12. Hi Manny, I have several patients that are coming in for a Complete Physical with their PCP; they have Original Medicare A/B; they have been informed that Medicare does not cover this service (code #99397); they say they have checked with their secondary insurance and a physical will be covered and they are willing to sign an ABN. Just making sure which G code modifier is correct for the physician to bill in these cases. It looks like GX would be the appropriate one, but want to make sure. Thank you for your help.

    • Karen — Adding the GX modifier to 99397 when a Medicare patient fills out a voluntary ABN for this service is correct.

      But keep in mind that even if you forget to obtain an ABN or the patient does not fill out the ABN properly, you can still bill the patient for the physical since it is not covered by statute.

      We have billed many a Medicare patient that had a 99397 performed and there was no ABN on file and collected. That said, the best practice is to inform your patient so they know ahead of time that they may be billed for the physical.

  13. We are not participating in the Medicare program, do to the fact that the equipment we provide is not in Medicare’s fee schedule. But we need the correct denial stating not covered service. Some articles say we must use GZ and some say GA and others GX, or GY. So confused at this point just need the correct denial for Medicaid to cover any idea’s. We need the process to go smoothly and we are small enough that we will be billing on paper which will make the time span seem like forever. Please Advise!!! Thank

  14. This information may be confusing for inexperienced billers. Only the designated “attending physician” is eligible to use the GV modifier. All other claims related to the hospice care must go to the hospice provider. The GW modifier can be selected when it can be shown by documentation that the services are not related to the hospice care.

    Modifiers should never be changed or added to claims unless the documentation has been reviewed and the use of the modifier is appropriate based on the documentation.

    Mary Lutes, CPC

  15. We are an ambulance company. We are getting Medicare denials transporting patients to therapeutic/diagnostic centers (D Modifier)i.e RD is residence to diagnostic center & DR is the return modifier. The facilities are NOT physicians (P Modifier) & not hospital (H modifier). Why are we getting denials for bona fide procedures/ICD9 codes in these facilities?
    Help. Thanks

  16. Being denied consults when billing Medicare because not using proper modifier (was using AH), but can find no human being to talk to at Medicare and havce been looking on-line and can’t find. Any Help? This is for a psychological practice. It is my understanding the new consult code is 90791 (90792 for our psychiatrists).

    Thanks, Debbie

  17. […] The analysis of any medical billing or coding question 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 (as well as coding itself) 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.Source: capturebilling.com […]

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The analysis of any medical billing or coding question 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 (as well as coding itself) 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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