DME MACs Revise Statement on GA/GY Modifier Usage with ABNs

The DME MACs have issued revised articles concerning the use of GA and GY modifiers with the Advance Beneficiary Notice of Noncoverage (ABN).
The articles specifically instructed DME suppliers on the GA and GY modifiers. Said the articles: “Suppliers are reminded that modifiers GA and GY should never be coded together on the same line for the same HCPCS code. It is important to distinguish situations in which an item is denied because it is statutorily excluded or does not meet the definition of any Medicare benefit from those situations in which an item is denied because it is not reasonable and necessary.”

The articles stated that the GA modifier “indicates that the supplier has a waiver of liability statement on file…. If the supplier issues a properly executed ABN with Option 1 selected by the beneficiary, the DMEPOS supplier must submit the claim to Medicare using the GA modifier on the HCPCS code that is expected to be denied.”

“Option 1” indicates the beneficiary wants to receive the item even if Medicare declines to pay for it and the beneficiary must pay for the item himself/herself.
The GY modifier “indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit,” the articles said. “Some local coverage determinations (LCD) require the use of the GY modifier when the item or service may be excluded from coverage. In this situation, suppliers are instructed to code the claim with the appropriate HCPCS code indicated in the LCD and append the GY modifier.” An example of a statutory exclusion would be a wheelchair used for mobility outside the home, the articles added.

This article originally appeared in the February 2009 issue of Mobility Management.

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