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Advance Beneficiary Notice of Non-coverage Modifiers Fact Sheet

The following are claim modifiers associated with advance beneficiary notice of noncoverage (ABN) use. For specific instructions on filing claims associated with ABNs, see the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-04, Chapter 1, Section 60.

GA Modifier- Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case

Use this modifier to report that an advance written notice was provided to the beneficiary of the likelihood of denial of service as being not reasonable and necessary under Medicare guidelines.

Report when you issue a mandatory ABN for service as required and is on file.
You do not need to submit a copy of the ABN, must be available upon request.
The most common example of these situations would be services adjudicated under a Local Coverage Decision.
The presence or absence of this modifier does not influence Medicare's determination for payment.
Line item is submitted as covered and Medicare will make the determination for payment.
If it's determined that the service is not payable, the claim denial is under "medical necessity denial."
It is inappropriate to use the GA modifier when the provider/supplier has no expectation that an item or service will be denied.
Do not use on a routine basis for all services performed by a provider/supplier.

GX Modifier - Notice of Liability Issued, Voluntary Under Payer Policy

Use this modifier to report when you issue a voluntary ABN for a service that Medicare never covers because it is statutorily excluded or is not a Medicare benefit.

Line items submitted as non-covered will be denied as beneficiary liable.
You may use this modifier in combination with the GY modifier.

GY Modifier - Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit

Use this modifier to report that Medicare statutorily excludes the item or service or the item or service does not meet the definition of any Medicare benefit.

Services provided under statutory exclusion from the Medicare Program; the claim would deny whether or not the modifier is present on the claim. 
It is not necessary to provide the patient with an ABN for these situations. 
Situations excluded based on a section of the Social Security Act. 
Modifier GY will cause the claim to deny with the patient liable for the charges. 
Do not use on bundled procedure or on add-on codes.
Line items submitted as non-covered and will be denied as Patient Responsibility
You may use this modifier in combination with the GX modifier.

GZ Modifier - Item or Service Expected to Be Denied as Not Reasonable and Necessary

Use this modifier to report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued.

This modifier is an informational modifier only.
Medicare will adjudicate the service just like any other claim.
If Medicare determines that the service is not payable, denial is under "medical necessity." The denial message will indicate that the patient is not responsible for payment.
If either the beneficiary or provider requests a review, the modifier tells us an ABN was not given, and this could help in completing the review quickly.
Medicare will auto-deny services submitted with a GZ modifier. The denial message indicates that the patient is not responsible for payment; deny provider liable.
If either beneficiary or provider requests a review, the modifier tells us that an ABN was not given.

References

Appeals Frequently Asked Questions (Part B)

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Last modified:  02/13/2017