Medical billing is a vast field and often sees new challenges thrown at healthcare providers and RCM professionals. One of the arduous tasks people in the billing industry currently face is the correct use of modifiers while billing Medicare. These modifiers are GA, GX, GY, and GZ.
If you’re also a healthcare provider or working in the RCM industry and are troubled by these modifiers, this blog post is for you. In this piece, we will talk you through helpful information regarding GA, GX, GY, and GZ modifiers, such as:
- What are these modifiers?
- Their descriptions
- Their usage by providers
- Correct use cases
- Which modifiers are used together
- The role of Advance Beneficiary Notice (ABN)
GA, GX, GY, and GZ
These are the four most common medical coding modifiers used for billing and reimbursements of medical services.
As a healthcare professional or someone working in the RCM industry, you may know very well how taxing medical billing and coding can be for service providers and healthcare facility staff.
However, understanding the correct usage of these modifiers can surely help you achieve a high percentage of accurate claim submission and receive full and timely payments.
Modifiers
These four modifiers are double-digit codes attached to CPT or HCPCS procedure codes for extra information regarding services provided without changing the meaning of the original code.
They help to specify such circumstances that are related to the service or procedure of the payor. These two-digit modifiers have a specific purpose of indicating ABNs’ status.
If you’re unaware of what an ABN is, let us tell you. An ABN is a notice sent to Medicare beneficiaries notifying them about certain services that aren’t included in Medicare coverage.
So, the beneficiaries may have to pay for them from their pocket. This prior notification gives the beneficiary time to decide whether they want the services or not.
Now that you know about these modifiers, have you wondered about the primary aim of these codes? Their usage on the claim form is to clarify if an ABN was furnished and whether the patient is to be charged or denied charges.
Definitions of Modifiers (GA, GX, GY and GZ)
According to medisysdata, the following are the simple definitions of these modifiers. These descriptions will make it easy for you to understand their concept and usage.
GA: Waiver of liability statement issued as required by payor policy
GX: Notice of liability issued, voluntary under payor policy
GY: The service provided is statutorily excluded from the Medicare program
GZ: Item or service expected to be denied as not reasonable and necessary
ABN Claim Modifiers in detail
Now, let’s tell you about these modifiers in detail, their definitions, usage, and correct use cases.
GA Modifier
Providers use GA modifiers to notify the beneficiary about non-coverage of a specific service for which an Advance Beneficiary Notice (ABN) is on file.
Simply saying, this notice lets the patient know in advance that a certain service or treatment is expected to be rejected by Medicare.
Hence, they will not pay if the patient goes ahead with the procedure. Here, it is worth noting that ABN must not be attached to the claim. However, it must be presented if required or when asked for.
Imaginary Case
Take the example of a patient visiting a therapist for sports massage treatment. If Medicare does not deem sports massage a necessary medical procedure, it will not provide coverage for it.
The therapist will notify the patient about the scenario by issuing an ABN. It will contain information like non-coverage by insurance and expected out-of-pocket costs.
Here, the provider will add a GA modifier on the claim to show that an Advance Beneficiary Notice was issued prior to the service provided.
Correct Use of The GA Modifier
The provider must only use the GA modifier in case the service is likely to be rejected on the basis of not medically essential. And that the use of ABN is on file.
Medicare instructs to add a GA modifier to a particular miscellaneous HCPCS code.
Applying this code gives the provider peace of mind that Medicare will consider the beneficiary/patient liable for payment if the case is denied.
GX Modifier
This modifier is issued when a healthcare professional must notify the patient that Medicare doesn’t pay for such medical items before they are delivered. This is a voluntary ABN that lets the patient know in advance about the liability for the payment.
For instance, when a supplier knows that insurance won’t pay for a specific item based on Medicare rules.
Or, in case that kind of medical item isn’t considered a Medicare benefit by Congress, the supplier informs the beneficiary in advance that they will have to pay for it from their own pocket.
Imaginary Case
A patient requires a laser device for hair removal or equipment for any other cosmetic procedure that either Medicare doesn’t consider medically essential or has features it doesn’t cover.
In such a case, the medical supplier will add a GX ABN to the claim and have it signed by the patient before submission. This code is affixed to the document showing that the patient was notified.
Correct Use of The GX Modifier
It is important to consider that Medicare doesn’t cover convenience services like contact lenses, dental care, and comfort items like cosmetic tools, hospital phones, etc. If an insurance holder orders eyeglasses or hearing aids, these may not be delivered.
Here, adding an ABN is not mandatory, as Medicare will reject the claim immediately, leaving the beneficiary liable to pay for the instruments and devices.
In case the supplier does include a voluntary ABN, they have to add the GX modifier combined with the GY modifier before submitting the claim to Medicare.
Although it will result in a straightaway denial, the supplier may still include the ABN as a courtesy to the patient.
GY Modifier
The addition of the GY modifier in the claim is done to notify Medicare that a certain service or item is ‘statutorily excluded’ from their program. Simply put, a medical service or helping aid doesn’t fit into Medicare’s definition of a benefit they usually cover.
This means the law limits Medicare from paying for particular things or only paying for such medical equipment or medicines in special cases.
Imaginary Case
Statutory excluded items or services are those that Medicare doesn’t cover. These include most dental services – tooth extractions, cleaning, and fillings – hearing aids, eye exams, and glasses – contact lenses, sunglasses – or personal comfort items.
In the same way, some items do not fall under Medicare benefits. These include durable medical equipment to be used outdoors, prosthetic devices aiding impermanent conditions, and immune suppressant medicines not related to a covered transplant.
Submitting a claim for any such items or services to Medicare the normal way means a denial. The inclusion of a GY modifier in medical billing is a way to submit a claim for non-covered services and items. It is highly likely that Medicare will not pay for it.
However, adding the modifier compels the insurance to review the claim and, in some cases results in patients paying less for the item or service.
One benefit of the GY modifier is that it helps outright denial of a claim and means special circumstances. From the patients’ point of view, this modifier means the difference between lowering some financial assistance or nothing.
Correct Use of The GY Modifier
The GY modifier is included to notify and get a denial from the insurance for a non-covered item or service. This implies that the requested item isn’t covered. In plain words, it is to let Medicare know that the requested item is not included; hence, doctors use this modifier.
Doctors, physicians, and healthcare providers affix it to obtain beneficiary-liable denial. It isn’t covered under the policy, and the patient is directly responsible to pay for it out-of-pocket.
GZ Modifier
The last of these modifiers, GZ, when appended to a claim, means Medicare doesn’t consider the desired treatment necessary or reasonable.
So, when this modifier is included, they outright deny the claim even without going into the details.
Imaginary Case
A doctor prescribes a costly new medicine to a patient. When the claim is submitted, the coverage provider may decide in favor of the cheap options or standard treatments to be tried first.
When a physician sends a claim for an expensive new medication that Medicare deems unnecessary, they can deny it using a GZ modifier.
Correct Use of The GZ Modifier
The correct usage of the GZ modifier is done to point towards that instance when ABN wasn’t issued for a specific service.
The GZ modifier must be used in case an ABN may be essential but wasn’t obtained or when the ABN was secured but not considered valid.
Note: All claims with a GZ modifier will face direct denial and won’t undergo a complex medical review.
Need Help With Correct Modifiers?
Help is at hand in the form of I-Med Claims. Our professional medical billers know the intricacies of ABN and use accurate modifiers, i.e., GA, GX, and GY.
We know these modifiers are complex, and appending inappropriate ones leads to claim denials, pending payments, and stress for patients, healthcare providers, and even the medical billing company.
Our team of highly qualified medical billers, based on their skill set and adeptness, know the correct usage of modifiers for certain cases.
We are known to review each claim thoroughly with extreme care and utmost dedication. It helps us ensure the correct usage of GA, GX, and GY modifiers to the claims.
Thanks to our 25+ years of RCM experience and our knowledge of insurance requirements, we know how and where to use these modifiers so that your claims are correct and pass on the first attempt.
Just contact us via call, quick chat, or email, and our specialists will guide you on modifiers and their selection for usage, depending on the requirements.
