When to use medicare abn CLAIM Modifiers

When to use Medicare's ABN Advanced Beneficiary Notice Claim Reporting Modifiers

ABN is NOT something you can routinely give to Medicare Beneficiaries (your patients!)

There are guidelines we need to follow and the ABN can only be used when (any of the following applies);

1. If you think Medicare will likely deny payments for an item or service; 
2. Medicare may cover the service but not likely medically necessary for the particular patient;
   
3. Medicare consider the service as "not a Medicare benefit";

Here are your Medicare ABN Modifiers that you can utilize

GA: (Waiver of liability statement issued as required by payer policy, individual case). Use this modifier to report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN, but you must have it available on request.

GX: (Notice of liability issued, voluntary under payer policy). Use this modifier to report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier in combination with modifier GY.

GY: (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract 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. You may use this modifier in combination with modifier GX.

GZ: (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.

​WHEN NOT TO USE AN ADVANCE WRITTEN NOTICE OF NONCOVERAGE

​Do not use an advance written notice of noncoverage for items and services you furnish under Medicare Advantage (Part C) or the Medicare Prescription Drug Benefit (Part D).
​
You are not required to notify the beneficiary before you furnish items or services that are not a Medicare benefit or that Medicare never covers, such as:

1. Services when there is no legal obligation to pay
2. Services authorized or paid by a government entity other than Medicare (this exclusion does not include services paid by Medicaid on behalf of dual eligibles)
3. Services required because of war
4. Personal comfort items such as radios and televisions
5. Eye examinations for prescribing, fitting, or changing eyeglasses
6. Hearing aids

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