Compliance with Medicare is one of the most important challenges associated with medical billing. Using the right Medicare modifiers is essential for timely and accurate reimbursement. When submitting claims to Medicare it is necessary to show whether the patient was provided with an Advance Beneficiary Notice (ABN) or Medicare waiver of liability. The patient should be given the ABN prior to the provision of a service or procedure. In the absence of a signed ABN, the patient cannot be billed and the claim would have to be written off if denied by Medicare.

The top four Medicare modifiers providers should know about are:

  • GA Modifier: This modifier indicates that an ABN has been provided to the patient.  It will allow the provider to bill the patient if not covered by Medicare. When this modifier is used, Medicare will automatically assign the patient liability if the claim is denied. For instance, if the reason for providing a particular test is not medically necessary, the provider would expect the claim to be denied. So, before the test is performed, the patient is made to sign the ABN which explains that the claim will be denied. The patient will have to pay for the service.
  • GX Modifier: The modifier indicates that the provider has an ABN on file and that the patient has been voluntarily notified about non-covered Medicare services. Medicare only requires the ABN be used to inform beneficiaries when services will be denied as “not reasonable and necessary” as for instance in the case of maintenance care spinal CMT. Providers are not required to notify patients that non-covered services like exams, x-rays, physical medicine services will not be covered.
  • GY Modifier: This modifier is used for non-covered Medicare services. It is necessary for all services other than manual manipulation of the spine, including x-rays, extra-spinal CMT, therapy modalities, and exams. GY is not used on maintenance care spinal CMT.
  • GZ Modifier: The ABN is not on file. Use this modifier when an ABN should have been signed, but was not. It indicates to Medicare that the provider realizes that an error has been made. Payment cannot be collected from the patient.

To use the right Medicare modifiers and ensure timely reimbursement, outsource your billing tasks to an established medical billing company.  A professional service provider would have a team of medical billing specialists well versed in all aspects of medical billing on the job.