Medical Billing and Coding using GA Modifiers

Medical billing and modifiers go hand in hand. As a medical biller you will need to know when to use a modifier in order to get paid out and sometimes it may feel like some crazy game that no one really understands the rules of. But play we must and so here is my take on the GA modifier.
When to use a GA Modifier?
- When you feel the item or service will be denied as not reasonable and necessary and a Advanced Beneficiary Notice (ABN) was given to the beneficiary for signature.
- When you feel you will receive so-called “Medical Necessity” denials
- The GA Modifier also may be used with assigned and unassigned claims for DMEPO’s where one of the following Part B “technical denials” may apply
o Prohibited telephone solicitation
o No supplier number
o Failure to obtain an advance determination of coverage

You are required to attach the GA modifier anytime you obtain a signed ABN form and you furnish services.

Example:
A patient with Medicare primary benefits visits her chiropractor for an adjustment on the back and has carpal tunnel symptoms. The patient requests an adjustment on the wrist for the carpal tunnel and the chiropractor explains that these services are not covered by Medicare. The patient insists she would still like the adjustment so the provider presents the patient with the ABN form. Once the ABN form is signed the chiropractor can complete services for the carpal tunnel.

Who pays on procedure codes with GA modifier?
Medicare will most likely deny the claim and indicate on the EOB that the beneficiary (patient) is responsible for these services.

What happens if I don’t use the GA modifier?
Medicare will most likely deny the claim and indicate on the EOB that the beneficiary (patient) is NOT responsible for these services and you CAN NOT collect from the patient. If you billed this incorrectly you can go through the appeals process. Medicare does state the office is responsible for attaching the GA modifier anytime the office has that patient sign an ABN form. Failure to attach this modifier may result in fraud and abuse implications by Medicare.

Suggestion:
Identify if your medical billing software allows you to default modifiers per procedure code per carrier. Once this is setup you won’t have to worry about making sure the correct modifiers are attached.

To read additional articles on Medicare Billing check out: Medicare Medical Coding and Billing Courses

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