As per the latest CMS regulation, all claims with modifier GZ appended will be denied straight away. It is not unusual even in the best-run medical practices that the physician performs a noncovered service and doesn’t get an ABN signed.
If you should have had a patient sign an advance beneficiary notice (ABN) but failed to do so, you should append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the noncovered service the physician provided. The advantage to reporting modifier GZ is to avoid the potential for fraud and abuse charges — by appending this modifier, you’re telling Medicare that you know you performed a noncovered service and you know they aren’t going to pay for it.
In the past, your modifier GZ claims were potentially subject to complex medical reviews, which can slow claims and create logjams in your billing processes. However, CMS’s new policy will ensure that these claims will be denied instantly.
“Effective for dates of service on and after July 1, 2011, contractors shall automatically deny claim line(s) items submitted with a GZ modifier,” states Transmittal 2148. Your explanation of benefits will list the denial codes CO (Provider/supplier liable) and 50 (These services are non-covered services because this is not deemed a ‘medical necessity’ by the payer).
Don’t allow yourself to resort to modifier GZ. Have a policy in place to collect ABNs when necessary. To read Transmittal 2148, visit www.cms.gov/transmittals/downloads/R2148CP.pdf
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