(Medicare Claims Processing Manual)

* These modifiers are not non-covered by definition, but rather are commonly used on non-covered lines   In the past, modifiers were more frequently used to qualify procedure codes submitted on professional billing formats.  Use of modifiers has increased in institutional billing over time, though institutional claims do not always require the use of procedure codes in addition to revenue codes.  Institutional shared systems require procedure codes to be present any time a modifier is used, whether the line is covered or not.  Providers should use explicit procedure or HCPCS coding to describe services and items they deliver, even when submitting t hese items as non -covered.  In cases in which providers need to submit a non- covered service for which Medicare institutional claims have not required HCPCS coding in the past, such as with drugs or supplies, the following HCPCS code can be used with the appropriate revenue code in order to employ a modifier:  A9270 Non-covered item or service  Institutional shared systems will accept this code and it will be denied in all cases, since it is non-covered by Medicare by definition.  Liability will rest with the provider, unless a modifier is used to assign liability to the beneficiary  (i.e., - GL,  - GY), when the beneficiary has been informed, prior to service delivery, that he/she may be liable for payment. Note GA or KB modifiers cannot be used with this code since they require covered charges. Modifiers most likely to be used with ABNs or non- covered charges or liability notices are listed below.   Table:   Definition of Modifiers Related to Non -covered Charges/ABNs for Institutional Billing   Mod ifier HCPCS Modifier  Definition  HCPCS Coverage/  Payment/  Administrative Instruction  Notice Requirement/ Liability  Billing Use  Payment Result  EY No Physician or Other Licensed Health Care Provider Order for this Item or Service  None  None, cannot be used when HHABN or ABN is required, recommend documenting records; liability is provider unless other modifiers are used  (-GL or -GY) To signify a line -item should not receive payment when Medicare requires orders to support delivery of a item or service (i.e., TOBs 21x, 22x, 32x, 33x, 34x, 74x, 75x, 76x, 81x, 82x, 85x) When orders required, line item is submitted as non-covered and services will be denied  Mod ifier HCPCS Modifier  Definition  HCPCS Coverage/  Payment/  Administrative Instruction  Notice Requirement/ Liability  Billing Use  Payment Result  GA Waiver of Liability Statement Issued, as Required by Payer Policy  None  ABN required; beneficiary liable  To signify a line item is linked to the mandatory use of an ABN when charges both related to and not related to an ABN must be submitted on the same claim  Line item must be submitted as covered ; Medicare makes a determination for payment GK Reasonable and Necessary Item/Service Associated with a  GA or GZ modifier  None  ABN required if GA is used; no liability assumption since this modifier should not be used on institutional claims  Not used on institutional claims. Use GA or  GZ modifier as appropriate instead  Institutional claims submitted using this modifier are returned to the provider  GL Medically Unnecessary Upgrade Provided instead of Non-Upgraded Item, No Charge, No ABN  None  Cant be used if ABN/HHABN is required, COPs may require notice, recommend documenting records; beneficiary liable  Use only with durable medical equipment (DME) items billed on home health claims (TOBs: 32x, 33x, 34x) Lines submitted as non- covered  and will be denied  GY Item or Service Statutorily Excluded or Does Not Meet the Definition of Any Medicare Benefit  Non-covered by Medicare Statute (ex., service not part of recognized Medicare benefit)  Optional notice only, unless required by COPs; beneficiary liable  Use on all types of line items on provider claims.  May be used in association with modifier GX.  Lines submitted as non- covered  and will be denied  Mod ifier HCPCS Modifier  Definition  HCPCS Coverage/  Payment/  Administrative Instruction  Notice Requirement/ Liability  Billing Use  Payment Result  GZ Item or Service Expected to Be Denied as Not Reasonable and Necessary  May be non -covered by Medicare  Cannot be used when ABN or HHABN is actually given, recommend documenting records; provider liable Available for optional use on demand bills NOT related to an ABN by providers who want to acknowledge they didnt provided an ABN for a specific line  Lines submitted as non- covered  and will be denied  KB Beneficiary Requested Upgrade for ABN, more than 4 Modifiers on a Claim  None  ABN Required; if service denied in development, beneficiary assumed liable   Use only on line items requiring more than [2 or ] 4* modifiers on home health DME claims (TOBs 32x, 33x, 34x)  Line item submitted as covered , claim must suspend for development  QL Patient pronounced dead after ambulance called  None  None, recommend documenting records; provider liable Use only for ambulance services  (TOBs: 12x, 13x, 22x, 23x, 83x, 85x) Mileage lines submitted as non-covered  and will be denied; base rate line submitted covered  TQ Basic life support transport by a volunteer ambulance provider  Not payable by Medicare  None, recommend documenting records; provider liable Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x) Lines submitted as non- covered  and will be denied  GX Notice of Liability Issued, Voluntary Under Payer Policy  None  Used when a provider issued an ABN on a voluntary basis; beneficiary liable  Use on all types of provider claims when a voluntary notice has been issued.  May be used in association with modifiers GY or used separately.   Lines submitted as non- covered  and will be denied   * NOTE : Many provider systems will not allow the submission of more than two modifiers.  In such cases, despite the official definition and the capacity of the Medicare systems to take in five modifiers on a line with direct EDI submission, contractors processin g home health claims should educate that it is appropriate to use this modifier when three modifiers are needed if there is a two -modifier limit.   All modifiers listed in the chart immediately above need to be used only when non-covered services cannot be split to entirely non- covered claims.  Modifiers indicating provider liability cannot be used on entirely no payment claims for which the beneficia ry has liability. Inappropriate use of these modifiers may result in entire claims being returned to providers.   60.4.3  Liability Considerations for Bundled Services  (Rev. 2783, Issued: 09- 10-13, Effective: 09 -30-13, Implementation: 09- 30-13)  Some Medicare payment policies, for outpatient services, group or bundle several items or services into a single unit for payment.  Questions arise in such cases, in terms of notifying beneficiaries of liability and billing, when some of the services in the bundle are thought to be covered, and some are not.  Chapter 30 of this manual states in several sections that ABNs may not be used to shift liability to a beneficiary in the case of services or items for which full payment is bundled into other payments; that is, where the beneficiary would otherwise not be  liable for payment for the service or item because bundled payment is made by Medicare.  Using an ABN to collect a charge for an individual items or service from a beneficiary where full payment is made for that and other care on a bundled basis constitut es double billing.   As a result of this policy, an ABN has to apply to all of a bundled service, or none of it.  This means all of a bundled service must be billed as noncovered, or none of it. Therefore, as long as part of a bundled service is certain to be covered or medica lly necessary, billing the entire bundled service as covered is appropriate. Medicare adjudication may still result in all, part or none of such services being paid, or something submitted as one type of bundled payment being re -grouped into another type of payment.  If the entire bundle is certain to be non- covered, the service should be billed as noncovered.  If there is overall doubt as to the medical necessity of the bundle, such as when a Medicare benefit does not seem to be medically necessary, then the instructi ons for billing in association with an ABN or for demand billing would apply.  This is always true when necessity is in doubt relative to all services in the bundle, but may also be used if a provider is uncertain of necessity of the majority services, or if there is discomfort in billing the entire bundle as covered for a specific reason.   60.5- Coding That Results from Processing Noncovered Charges  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  Codes Returned to Providers and Beneficiaries   After processing is complete, remittance advice notices are used to explain to providers the difference between the charges they submitted for payment and what Medicare paid on their claim.  The Medicare Summary Notice, or MSN, is used at the same time to inform beneficiaries about any payments made on their behalf.  Liability for noncovered charges is communicated using the Group Code on the remittance advice.  When the beneficiary is liable, contractors use Group Code PR.  When the provider is liable, contractors use Group Code CO.  Contractors shall deny services that are submitted with modifier GZ.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.  Group Code: CO CARC: 50  RARC: N/A  MSN: 8.81  Contractors shall deny services that are submitted with modifier GY.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.  Group Code: PR CARC: 96  RARC: N425  MSN: 16.10  Codes Used by Medicare Contractors  Medicare contractors use nonpayment codes when transmitting institutional claims to CWF in cases where payment is not made.  Claims where partial payment is made do not require nonpayment codes.  Both the shared system for institutional claims and CWF react to CMS -created non -payment codes on entirely noncovered claims.  The standard system must enter the appropriate code in the "Non-payment Code" field of the CWF record if the non-payment situatio n applies to all services present on the claim.  It does not enter the nonpayment code when either partial payment is made, or payment is made in full by an insurer primary to Medicare.  These codes alert CWF to bypass edits in processing that are not appropriate in nonpayment cases.  Nonpayment codes also alert CWF to update a beneficiarys utilization records (deductible, spell of illness, etc.) in certain situations.  Nonpayment codes themselves do not assign liability to provider or beneficiary on Medicare claims.   Medicare contractors and systems use the following nonpayment codes:  Code  Contractor Uses  Effect on Processing  B Placed on Part B -paid inpatient claims when prior to claim From date either:   Benefit and/or lifetime reserve days are exhausted;  Full day or coinsurance days are exhausted;  Beneficiaries elected not to use lifetime reserve days.   Charges are processed as noncovered;  utilization not chargeable;   cost report days not applied. R Placed on claims when:    SNF inpatient services are denied for reasons other than lack of medical necessity or care being custodial in nature;   Provider failed to file claims within timely filing limits;   Beneficiary refused to request benefit on a claim.   Charges are processed as noncovered and there is no payment;