Advance Beneficiary Notices of Non-Coverage Modifiers

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• -GA Modifier
• -GX Modifier
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Effective April 1, 2010, two HCPCS level 2 modifiers have been updated to distinguish between voluntary and required uses of liability notices:

In Change Request 6136, released September 5, 2008, CMS revised instructions for providers in the use of ABNs. Prior to these instructions, providers who voluntarily issued patients notices announcing that particular services were either excluded from Medicare coverage by statute, or were services for which no Medicare benefit category exists, used the Notice of Exclusion from Medicare Benefits form (NEMB–now a retired form) or notices that they developed themselves.

Effective March 3, 2008, CMS implemented the use of the revised ABN, which combined the general Advance Beneficiary Notice (ABN-G) and laboratory Advance Beneficiary Notice (ABN-L) into a single form, with form number CMS R-131. With these revised instructions, providers were allowed for the first time to use ABNs to voluntarily provide such notices.

Change Request 6563, from which this article is taken, announces that two HCPCS level 2 modifiers have been updated to allow the voluntary uses of liability notices to be distinguished from the required uses. Specifically, modifier -GA has been redefined to mean “Waiver of Liability Statement Issued as Required by Payer Policy.” It should only be used to report when a required ABN was issued for a service, and should not be reported in association with any other liability-related modifier and should continue to be submitted with covered charges. Please note that Medicare systems will now deny institutional claims submitted with modifier -GA as a beneficiary liability (rather than subjecting them to possible medical review), and the beneficiary will have the right to appeal this determination. Medicare processing of professional claims with this modifier is not changing.

In addition, a new modifier, -GX, has been created with the definition “Notice of Liability Issued, Voluntary Under Payer Policy,” which should be used to report when a voluntary ABN was issued for a service. You may use the -GX modifier to provide beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute and, in these cases, you may report it on the same line as certain other liability-related modifiers. Please note that the -GX modifier must be submitted with non-covered charges only, and your claim will be denied as a beneficiary liability.

You should be aware of some details in the use of these modifiers.

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-GA Modifier 

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-GX Modifier 

The following situations are required by statute that an ABN be issued:

In the following situations, ABN use is voluntary. ABNs are not required for care that is either statutorily excluded from coverage under Medicare (ie, care that is never covered) or fails to meet a technical benefit requirement (ie, lacks required certification).

You can find more information about billing for services related to voluntary uses of Advance Beneficiary Notices of Non-coverage (ABNs) by going to CR 6563, located at http://www.cms.hhs.gov/Transmittals/downloads/R1840CP.pdf on the CMS website and MLN 6163 http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm6136.pdf.