January 2, 2008
The Advance Beneficiary Notice of Noncoverage and Correct Use of Modifiers GA and GY - Revised
Both Medicare beneficiaries and durable medical equipment, prosthetics,
orthotics, and supplies (DMEPOS) suppliers have certain rights and
protections related to financial liability under the Fee-for-Service
(FFS) Medicare program. These financial liability and appeal rights
and protections are communicated to beneficiaries through Advance
Beneficiary Notices of Noncoverage (ABN) given by suppliers.
An ABN is a written notice the supplier gives to a Medicare beneficiary before providing items and or services that are expected to be denied by Medicare based on one of the following statutory exclusions:
- The item or service may be denied as "not reasonable and necessary" pursuant to Section 1862(a)(1) of the Social Security Act
- The item or service may be denied due to an unsolicited telephone contact pursuant to Section 1834(a)(17)(B)
- The supplier number requirements not being met pursuant to Section 1834(j)(1)
- Denial of a request for Advance Determination of Medicare Coverage (ADMC) pursuant to Section 1834(a)(15)
When an item or service is provided to a Medicare beneficiary and is expected to be denied based on one of the four exclusions listed above, it is the responsibility of the supplier to notify the beneficiary in writing through the use of the ABN before the item or service is delivered or purchased. 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 each Healthcare Common Procedural Coding System (HCPCS) code that is expected to be denied. The GA modifier indicates that the supplier has a waiver of liability statement on file.
Statutorily Excluded Items
The GY modifier indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. 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. Some examples of statutory exclusions where the GY modifier is required per policy would include:
- An infusion drug not administered using a durable infusion pump
- A wheelchair that is for use for mobility outside the home
To determine if an exclusion of Medicare benefits exist, suppliers
must review the applicable LCD and policy article for the item or
service being provided.
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 at item is denied because it is not reasonable and necessary. Some examples of statutorily excluded items or situations include, but are not limited to:
- eyeglasses or contact lenses—except those provided following cataract removal or other cause of aphakia;
- Durable Medical Equipment and related accessories and supplies provided to patients in nursing facilities;
- personal comfort items; and
- orthopedic shoes or shoe inserts—other than those covered under the therapeutic shoes for diabetics benefit or those that are attached to a covered leg brace.
A description of the statutory benefit items that are processed by the DME Medicare Administrative Contractors (MACs) can be found in the Jurisdiction C DME MAC Supplier Manual. Some examples of items or situations which do not meet the definition of a Medicare benefit include, but are not limited to:
- Parenteral or enteral nutrients that are used to treat a temporary (rather than permanent) condition;
- Enteral nutrients that are administered orally;
- Infusion drugs that are not administered through a durable infusion pump;
- Surgical dressings that are used to cleanse a wound, clean intact skin, or provide protection to intact skin;
- Irrigation supplies that are used to irrigate the skin or wounds;
- Immunosuppressive drugs when they are used for conditions other than following organ transplants;
- Most oral drugs;
- Oral anticancer drugs when there is no injectable or infusion form of the drug;
- Nondurable items (that are not covered under any other benefit category);
- e.g., compression stockings and sleeves;
- Durable items that are not primarily designed to serve a medical purpose;
- e.g., exercise equipment.
To access the LCDs and policy articles, please visit the CGS website at www.cgsmedicare.com. Select the DME MAC Jurisdiction C homepage, then click on the Local Coverage Determinations link.
Under the new instruction for the revised ABN, the Centers for Medicare & Medicaid
Services ( CMS ) advise that this form may be used to voluntarily
notify Medicare beneficiaries of an expected noncovered denial of
Medicare payment due to the statutory exclusion of an item or service,
or the item or service not meeting the definition of any Medicare
Section 1848(g)(4) of the Social Security Act states that items that are categorically excluded from Medicare benefits (i.e. hearing aids, personal comfort items, etc.) are not required to be submitted to the Medicare program by the supplier. However, if the beneficiary requests the supplier to submit the claim to Medicare, the claim should be coded with the designated HCPCS, however, neither modifiers GA nor GY are required. The supplier and the Medicare beneficiary will receive a patient responsibility denial for the noncovered services.
For additional instruction regarding the proper execution of an ABN, suppliers are encouraged to review the CMS Internet-Only Manual Medicare Claims Processing Manual, Chapter 30, "Financial Liability Protections," Sections 50 and 60 at: www.cms.hhs.gov/manuals.