New Advance Beneficiary Notice Modifiers Effective April 2010

On April 5, 2010, CMS revised the Advance Beneficiary Notice of Noncoverage (ABN) modifiers. The purpose of the new modifiers is to differentiate between voluntary and mandatory use of the liability notice.

The new modifiers are:

-GA –Waiver of Liability Statement Issued as Required by Payer Policy

-GX – Notice of Liability Issued, Voluntary under Payer Policy

The description of Modifier –GA was changed to indicate than an ABN was signed specifically because of a mandate in the payer’s policy. Medicare will auto deny institutional claims that are submitted with the modifier. There are no changes for practitioner claims, since practitioner claims are evaluated on Medicare’s medical necessity and frequency parameters. A bone density examination, which Medicare covers every two years, is a scenario where the use of an ABN is applicable, if the patient presents prior to the completion of two years. The patient’s Medicare Summary Notice will indicate that the patient is responsible for the service.

Modifier –GX can be used when a provider requests the beneficiary to sign an ABN for a non-covered service. Prior to April, the Medicare program did not require a practitioner to report a modifier if the patient voluntarily signed an ABN (or NEMB –Notice of Exclusions from Medicare Benefits) for a statutorily non-covered service. Now, there is a mechanism for the provider to inform Medicare that the patient was notified of the non-covered status of the service, prior to the service being rendered. Medicare will auto deny all claims that are submitted with the modifier, using claim adjustment reason code 50. The denial will indicate that the patient, not provider, is responsible for the charge. This modifier may be reported to Medicare along with modifier –GY – item or service statutorily excluded or does not meet the definition of any Medicare benefit. An example where the use of this modifier would be appropriate is when a Medicare beneficiary presents for a preventive medicine examination.

Additional information can be found in MedLearn Matters Article MM6563, dated February 19, 2010.

Written by: Marianne Russo, CPC, CMC