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ABN Modifiers GA, GX, GY, GZ and Their Correct Use Cases

Modifiers GA, GX, GY, and GZ are four of the many medical coding modifiers that are used in billing and reimbursement for healthcare services. As we know, coding and billing can often become complex tasks for providers and their staff. However, properly understanding and applying modifiers like these can make a world of difference when it comes to accurate claim submission and receiving proper payment.

Now, what exactly are modifiers? In simple terms, they are two-digit codes appended to CPT or HCPCS procedure codes that provide additional information about the services rendered without altering the meaning of the original code. Modifiers enable providers to indicate specific circumstances or variables related to the procedure or service to the insurance payer.

Regarding GA, GX, GY, and GZ, these four modifiers have a very particular purpose – they indicate the status of Advance Beneficiary Notices or ABNs. For those unfamiliar, an ABN is a notice given to Medicare beneficiaries to inform them that certain services may not be covered by Medicare and they may have to pay out-of-pocket. This allows the beneficiary to decide if they still want the provider to furnish the service.

Where do these modifiers come in? Well, they are used to make clear on the claim form whether an ABN was issued and if the patient is liable for denied charges. The modifiers are defined below:

GAThe waiver of liability statement has been issued in compliance with the payer’s policy requirements.
GXA voluntary notice of liability has been issued in accordance with the payer’s policy.
GYThis item or service is statutorily excluded and does not qualify as a Medicare benefit.
GZThe item or service is likely to face denial based on the assessment of being not reasonable and necessary.
ABN Modifiers and their descriptions.

Understanding ABN and Its Modifiers

An Advance Beneficiary Notice, ABN for short, is a friendly warning Medicare gives to its beneficiaries. Medicare wants its beneficiaries to know that some medical services or items their doctor suggests they get may not be covered under their Medicare plan. This notice empowers the beneficiary to make an informed decision on whether to proceed with the service, understanding that they may need to shoulder the financial responsibility if Medicare opts not to provide coverage.

For example, say a Medicare beneficiary is considering a specialized medical procedure. However, Medicare thinks that treatment is still too new or uncertain to cover. So here the doctor’s office will have the beneficiary sign an ABN saying that the beneficiary understands Medicare probably won’t pay for the medical procedure and that the beneficiary is responsible for paying the expenses for the medical procedure.

ABNs are meant for Medicare members, but many doctors use a similar kind of notice for patients with other insurance too. It’s always a good idea for doctors to be upfront with patients about what care costs and who’s paying for what. That way there are no surprises for anyone down the road.

The Medicare categorizes ABN in two types:

  1. Required/Mandatory ABN
  2. Voluntary ABN

Required ABN

A Required ABN is necessary when:

  • Medicare Payment Denial is Expected: Providers must issue a required ABN before providing a service or item that Medicare is expected to deny because it is not considered medically reasonable and necessary under Medicare coverage guidelines.
  • Frequency Limits: When a service exceeds Medicare’s coverage frequency limits.
  • Non-Covered Services: If a service is specifically excluded from Medicare coverage, such as routine dental care, hearing aids, or cosmetic surgery.

Voluntary ABN

A Voluntary ABN is used when:

  • Services Always Denied by Medicare: Providers can issue an ABN for services that Medicare never covers. However, it is not required by Medicare, but it is good practice to inform the patient.
  • Statutorily Excluded Services: Items or services that are always excluded from Medicare coverage (e.g., non-medically necessary services like elective procedures).
AspectRequired ABNVoluntary ABN
When IssuedWhen Medicare denial is expected for covered items/servicesFor services/items not covered by Medicare by law
Provider ObligationMandatory to issueOptional, at the provider’s discretion
PurposeProtect provider from financial liability; inform patient of potential costsInform patient about financial responsibility for non-covered services
CoverageCovered items/services that might be deniedNon-covered services (e.g., routine dental, hearing aids)
A comparison of the Required ABN vs. Voluntary ABN.

When to Issue an ABN

Issue an ABN in the following situations:

  • When providing services that are not considered medically necessary
  • For services that exceed Medicare coverage limits
  • When providing statutorily excluded services

Steps to Issue an ABN

  • Identify the Service: Determine if the service may not be covered by Medicare.
  • Inform the Patient: Explain why the service may not be covered and the potential costs.
  • Provide the ABN: Give the patient the ABN form to read and sign.
  • Document the ABN: Keep a copy of the signed ABN in the patient’s medical record.
  • Submit the Claim: Use the appropriate modifier (GA or GX) when submitting the claim to Medicare.

What are ABN Claim Modifiers?

ABN Modifiers are codes appended to a CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) code to indicate that an ABN has been issued and to reflect the patient’s choice regarding financial responsibility. The most common ABN modifiers are:

  • GA Modifier
  • GX Modifier
  • GY Modifier
  • GZ Modifier

GA Modifier

GA Modifier

The Modifier GA is used by providers to indicate that an Advance Beneficiary Notice of Noncoverage (ABN) has been issued for a particular service, and that the ABN is on file. This means that the patient has been informed in advance that the service may not be covered by Medicare, and that they will be responsible for payment if this is the case. It is important to note that a copy of the ABN does not need to be submitted with the claim, but it must be made available upon request.

For instance, let’s say a patient visits a dermatologist for a cosmetic procedure. Since this procedure is not medically necessary, Medicare will not cover it. The dermatologist would then issue an ABN to the patient, informing them of the noncoverage and the potential costs. The provider would then use Modifier GA on the claim to indicate that an ABN was issued, and that it is on file.

✅ Correct Use Case

➜ This modifier should be utilized when an item or service is anticipated to be denied on grounds of not being medically necessary, and an Advance Beneficiary Notice (ABN) has been correctly executed.

➜ It is recommended to attach Modifier GA to a specific or miscellaneous HCPCS code.

➜ By applying this modifier, providers can ensure that in case of denial, Medicare will automatically hold the beneficiary accountable.

❌ Incorrect Use Case

➜ Providers should refrain from combining GY, GZ, or GA modifiers on a single claim line. The repercussions of such an action are severe, as the claim will face denial if these modifiers are mistakenly used together.

➜ The GA modifier should not be paired with the KX modifier, as they are incompatible. The KX modifier serves a specific purpose, and its conjunction with GA could lead to complications in claim processing.

GX Modifier

GX Modifier

The GX modifier is used when a medical supplier gives a Medicare patient a voluntary ABN that Medicare won’t pay for a certain medical item before it’s delivered. If a supplier thinks Medicare won’t cover something according to Medicare’s rules or if Congress hasn’t included that kind of item as a Medicare benefit, the supplier has to let the patient know in advance that they’ll have to pay for it themselves.

For example, say a patient orders a top-of-the-line electric wheelchair that has features Medicare doesn’t usually pay for. The medical supplier would have the patient sign an ABN and then when the claim is submitted to Medicare, the GX modifier is added to show the proper notice was given.

✅ Correct Use Case

➜ If a beneficiary has an order for a shower chair, it’s important to note that Medicare considers this to be a convenience item and therefore noncovered. Because of this, an ABN is not required as the claim will be denied by Medicare and the beneficiary will be held liable. However, if the supplier decides to issue a voluntary ABN as a courtesy to the beneficiary, it’s important to include the GX modifier, along with the GY modifier, when submitting the claim to Medicare for an official denial.

❌ Incorrect Use Case

➜ Do not add this modifier to claims if an ABN has not been issued.

➜ Refrain from appending this modifier to claims for items that do not fall under statutorily excluded or defined benefit categories.

GY Modifier

GY Modifier

The GY Modifier tells Medicare an item or service is “statutorily excluded” or does not meet Medicare’s definition of a benefit they will normally cover. In plain talk, that means Medicare is prohibited by law from paying for certain things or will only pay for specific uses of certain medical equipment or drugs.

For instance, examples of statutorily excluded items are hearing aids, most dental products, and personal comfort items. Similarly, items that do not align with Medicare benefits include prosthetic devices for temporary conditions, immunosuppressive drugs unrelated to a covered transplant, and durable medical equipment designated for use outside the home. Billing Medicare for any of these things the normal way will surely end in denial.

The GY Modifier gives doctors a way to submit claims for these non-covered items and services regardless. Medicare will likely still not pay, but the modifier forces Medicare to at least review the claim and sometimes results in patients owing less. The modifier helps prevent outright rejection and allows for special circumstances. For patients, the modifier could mean the difference between some Medicare help and none.

✅ Correct Use Case

➜ This modifier is used to obtain a denial on a non-covered service, which means that the service is not included in the Medicare benefits. To notify Medicare that you know this service is excluded, it is recommended to use the Modifier GY.

➜ Append it to the claim to get beneficiary-liable denial. This means that the patient will be responsible for paying for the service out of pocket, as it is not covered by Medicare.

GZ Modifier

GZ Modifier

When a GZ modifier is attached to a claim, it means Medicare does not consider that treatment reasonable or necessary, so they will deny the claim straight away without bothering to review the details.

For instance, say a physician prescribes some expensive new drug for a patient. The insurance company may decide that cheaper, standard treatments should be tried first. So if the doctor submits a claim for that pricey new drug, Medicare can just slap a GZ modifier on it and be done.

✅ Correct Use Case

➜ The GZ modifier should be used to indicate instances where an ABN was not issued for a particular service.

➜ It should be applied when an ABN may have been necessary but was not acquired, or when an ABN was secured but is deemed invalid.

*Note: All claim line items submitted with a GZ modifier will be automatically denied and will not undergo a complex medical review.

Get Help Choosing the Right Modifiers

Having trouble figuring out when to use modifiers GA, GX, and GY?

Don’t worry, you’re not the only one. These modifiers are confusing and complex. Applying the wrong one can lead to denied claims, delayed payments, and headaches.

But there’s an easy solution – let our team of best medical billing experts determine the right modifier for your unique cases. We’ll carefully review each claim and ensure you use the appropriate GA, GX, or GY modifier. With decades of experience under our belts, we understand the nuances of these modifiers and stay up-to-date on the latest guidelines.

Contact us today to learn more about our modifier selection service.

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