Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs)

CR 6563 announces recent instructions for the use of modifiers in association with Advance Beneficiary Notices (ABN). Specifically, effective April 1, 2010, two HCPCS level 2 modifiers have been updated to distinguish between voluntary, and required, uses of liability notices. Those modifiers are:

1. Modifier – GA has been redefined to mean “Waiver of Liability Statement Issued as Required by Payer Policy,” and should be used to report when a required ABN was issued for a service.
2. A new modifier (-GX) has been created with the definition “Notice of Liability Issued, Voluntary Under Payer Policy” and is to be used to report when a voluntary ABN was issued for a service.

You should be aware of some details in the use of these modifiers.

GA Modifier:

• 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 non-covered 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

• 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 indicate 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.