New Codes and Modifiers to Bill Medicare for Denials

Vol. 11 •Issue 22 • Page 8
New Codes and Modifiers to Bill Medicare for Denials

KAthleen A. Mundy, BS, rn, ccs, cpc

Over the last several months, the Centers for Medicare and Medicaid Services (CMS) has addressed the issue of coding and billing Medicare for noncovered items and services. The most recent instructions appeared in transmittal B-01-58 (September 25), which updated previous transmittal B-01-30 issued on April 26. The guidelines, which take effect on Jan. 1, 2002, address the codes and modifiers that may be used to get denials from Medicare so that secondary payers may be billed.

The transmittals address the following.

- Discontinued codes and modifier GX;

- Clarification on use of HCPCS level II code A9270;

- Appropriate code assignments; and

- Use of the GA, GY and GZ modifiers.

Code Assignments

CMS announced that it has discontinued use of the following codes.

A9160 Non-covered service by podiatrist

A9170 Non-covered service by chiropractor

A9190 Personal comfort item, (non-covered by

Medicare statute)

In the April transmittal, the code description for A9270 (noncovered item or service) changed to “not valid for Medicare.” However, the September transmittal clarifies that although A9270 is invalid for claims submitted to carriers, it may be used for bills that durable medical equipment (DME) suppliers submit when there is no specific procedure code.

Also in the April transmittal, CMS stated that it would implement two newly developed codes (Q3015 [item or service noncovered] and Q3016 [item or service not reasonable and necessary]). However, in the September transmittal, CMS retracted this, and these will not be implemented after all.

Instead, providers should assign the HCPCS code that best describes the service provided, when one is available. If none is available, use a “not otherwise classified code” (NOC) with either modifier GY or GZ (See Modifier Choices below).

When you assign a NOC code, be sure to include a description of the services or items provided in item 19 of the HCFA-1500 form or submit an attachment. For electronic claims, report the information in the claims level note. If you need space for any additional narrative, enter the qualifier “ADD” in NTE01 then enter the additional narrative in NTE02.

Examples of an appropriate explanation include “claim submitted to receive denial for secondary payer” or “service performed by family member.” CMS gave carriers the option of specifying other explanations they want their providers and suppliers to use.

Modifier Choices

In the April transmittal, CMS announced its decision to discontinue use of modifier GX (service not covered by Medicare). It also announced the following two new modifiers that may be assigned with the specific or NOC code assigned.

GY Item or service statutorily excluded or does not meet the

definition of any Medicare benefit

GZ Item or service expected to be denied as not reasonable

and necessary

Medicare may cover certain items and services as reasonable and necessary under particular circumstances but not under other circumstances. When providers and suppliers furnish an assigned or unassigned service or item that they believe is not reasonable and necessary according to Medicare policies, the specific HCPCS code and the new GZ modifier should be used. But only use this modifier when the patient has not signed an advance beneficiary notice (ABN). When one has been signed, use the GA modifier instead. Never attach both GZ and GA to a code for the same item or service. Carriers will deny such claims as invalid.

CMS told Medicare payers not to auto-deny claims simply because of the code used but they may based on other criteria, such as improper diagnosis-to-procedure coding. Claims for noncovered services will be included in regular medical review procedures.

Kathleen A. Mundy is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.

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