New Revised ABN Modifiers

on Thursday, 12 November 2009. All News Items

In 2008, Medicare changed the regulations regarding use of the Advance Beneficiary Notice (ABN) to allow use of the ABN for voluntary notices.  Prior to this change, ABNs were only used to notify beneficiaries of services that were likely to be denied for reasons of medical necessity.  Providers could use the Notice of Exclusion of Medicare Benefits (NEMB) to notify beneficiaries of services that were excluded by statute or for which no Medicare benefit category exists.  The change retired the NEMB and allowed ABNs to be used for both mandatory and voluntary uses.

In Transmittal 1840, Medicare has updated two HCPCS modifiers to distinguish between voluntary and required uses of the ABN, effective April 1, 2010.

  • 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.
  • Modifier -GX is a new modifier with the definition “Notice of Liability Issued, Voluntary Under Payer Policy.”  It was created to be used to report when a voluntary ABN was issued for a service.

Modifier -GA should only be used to report when a required ABN was issued.  ABNs are required in order to shift liability to the beneficiary when otherwise covered services are expected to be denied, such as services that are not medically necessary based on coverage determinations.  Line items with the –GA modifier should continue to be submitted with covered charges.  Modifier -GA should not be reported in association with any other liability-related modifiers.  Medicare will deny institutional claims submitted with modifier -GA using claim adjustment reason code 50 and will assign beneficiary liability.

Modifier –GX should be used when beneficiaries are provided voluntary notices of liability for statutorily-excluded services.  Providers are not required to give notification of statutorily-excluded services, but may choose to do so to aid the beneficiary.  The –GX modifier must be submitted with non-covered charges only.  Your claim will be returned if the –GX modifier is reported on a line with covered charges.  It may be reported on the same line as modifiers –GY or –TS that indicate beneficiary liability.  It should not be reported on the same line with modifiers –EY, –GA, -GL, -GZ, -KB, -QL or –TQ.  Medicare will automatically deny lines submitted with modifier –GX and non-covered charges using claim adjustment reason code 50 and will assign beneficiary liability. 

Please refer to Transmittal 1840 or MLN Matters MM6563 for more information.

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