More often than not, when Medicare payers process denials in a speedy fashion, it spells bad news for your practice. But again when you are using modifier GZ, you are already anticipating a denial. CMS has made that happen faster with a new regulation indicating that all claims with modifier GZ appended will be denied straight away.
Why you’ll use GZ: It happens to even the best run medical practices – the doctor has just carried out a service that does not meet the Medicare criteria for coverage at the time of the visit and the patient did not sign an ABN.
Follow this GA, GZ and GY instance
A 68-year old low-risk Medicare patient comes in for annual exam; however Medicare paid for her Pap and pelvic exam in 2010. You tell the patient that Medicare will not cover that part of the exam this year; but then the patient requests the service anyway. The doctor takes a look at the encounter form for the services provided, and billing department sends the claim in to Medicare to get a denial in order that the patient’s secondary insurance will cover it.
In an ideal world, you would have had the patient sign an ABN so that you can apply modifier GA to the part of the exam that would normally be covered by Medicare.
However, sometimes the patient will refuse to sign the ABN or for other extenuating reasons, the patient didn’t sign it during the time of the service as is called for. In this situation, you have no ABN for the pelvic and Pap part of the annual, and office policy dictates that you bill both the non-covered preventive medicine services (for instance 99397 as well as G0101and Q0091 for the Medicare part of the exam.
When your billing department is all geared to submit the claim, you comprehend there’s no ABN. Therefore you should submit the claim as you would normally, adding a modifier GZ to the G and Q codes.
You should add modifier GY to the preventive code (for instance 99397) as usual, since you don’t need an ABN for a service that is never covered by Medicare.
Advantage and disadvantage of GZ: The advantage to reporting modifier GZ is to stay away from the potential for fraud and abuse charges. The drawback is that since your ob-gyn provided a service which Medicare considers not medically necessary, the patient will not be held responsible for payment. To put it in other words, your ob-gyn will have provided a free service.