NGS Analysis Shows Incorrect GA Modifier Usage

National Government Services (NGS), the Jurisdiction B DME MAC, says a recent analysis of redeterminations regarding pressure-reducing support surfaces showed frequent errors in usage for the GA modifier.

A bulletin issued last week to stakeholders said, "Results of the analysis identified that suppliers are often submitting claims with modifier GA appended and then later requesting a redetermination or reopening indicating they had appended the wrong modifier. Requests of this nature should rarely, if ever, occur for claims involving Group I, II, or III pressure-reducing support surfaces."

Instead, NGS says, "Suppliers are responsible for making a determination as to whether Medicare is expected to allow or deny a Group I, II or III pressure-reducing support surface and must append the appropriate modifier based upon that determination."

The bulletin also addressed the proper use of KX and GZ modifiers on Group I, II and III pressure-reducing support surfaces. Many policies require use of KX, GA or GZ modifiers "to indicate whether coverage criteria has or has not been met. The DME MACs will reject a claim line if the supplier does not include one of these modifiers as specified in the local coverage determination (LCD). The supplier is then required to resubmit the claim with the appropriate modifier. These claim rejections cannot be corrected through a reopening or redetermination."

NGS says using the KX modifier indicates that requirements in the medical policy have been met, while the GA modifier is a waiver of liability - i.e., an indication of expected denial as not reasonable and necessary, with an Advance Beneficiary Notice of Noncoverage (ABN) on file.

The GZ modifier indicates the item or service is not reasonable and necessary and is expected to be denied as such, with no ABN on file.

NGS added regarding use of the KX modifier, "The KX modifier serves as an attestation by the supplier that the requirements for its use that are defined in the particular local coverage determination are true for that specific beneficiary. It must not be added indiscriminately just because it is needed to get the claim paid.

"In the Group I, II, and III pressure-reducing support surface policies, the instructions for the use of the KX modifier clearly specify that the supplier must have the documentation (e.g., copies of the patient's medical record, test reports, etc.) in their files before they may submit a claim line with the modifier. If they do not, the modifier must not be added."

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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