Struggling to understand when and how to use the GA modifier correctly? Let us be your guide! It is common knowledge that modifiers are extremely useful for delivering additional information to payers. In simple terms, these two-digit codes help them determine how to reimburse a particular service or procedure.
Some modifiers, including modifier GA, are specifically used in Medicare claims. Healthcare providers use the GA modifier when they think Medicare will deny their claim due to a lack of medical necessity. But what exactly does this code indicate, and why is it so important for billing compliance? Let’s find out!
What is a GA Modifier?
GA modifier simply indicates that the healthcare provider has issued a Waiver of Liability to the patient for a service that Medicare is likely to deny. Before moving on to the explanation, let us first clarify what a Waiver of Liability is.
A Waiver of Liability, also known as an Advance Beneficiary Notice (ABN), is a written notice given to a Medicare Beneficiary by a healthcare provider before rendering a care service or product. Providers issue this when they believe that Medicare may not cover an item or service based on one of the following reasons:
- The service/item is not medically necessary based on Medicare’s guidelines.
- The claim is missing a valid provider number.
- The provider made prohibited, unsolicited calls to Medicare beneficiaries to sell an item or service.
- A non-contract provider offered an item listed in a Competitive Bidding area.
- The patient has exceeded the coverage threshold (how often a service or item can be received).
- Medicare denied a request for an Advanced Determination of Medicare Coverage (ADMC).
This notice allows a patient to make an informed decision before receiving any treatment—to either decline the service or proceed with it and bear the financial burden.
In this case, the GA modifier serves as proof. It indicates that an ABN notice was issued to the patient, informing them about coverage limitations. However, despite understanding that Medicare does not cover a specific service or item, the patient has chosen to receive it.
But why is it so important? Without modifier GA, healthcare providers cannot bill patients if Medicare denies their claim. In simple words, this modifier is essential for avoiding payment disputes.
Scenarios Where a GA Modifier is Applicable
By now, you must know that healthcare providers, including physicians, nurse practitioners, lab technicians, and other qualified professionals, apply modifier GA to medical claims to notify Medicare that the patient has agreed to pay for the service in case of a denial.
Still unsure about its correct application? Here are a few exceptional cases where you can use the GA modifier:
Anesthesia Service for A Low-Risk Patient
Let’s consider a simple example! A 47-year-old woman visits a gastroenterologist for a routine colonoscopy (CPT code 45378). The patient is not at high risk, so the physician recommends conscious sedation, which is included in the procedure and covered by Medicare. However, the patient requests for an anesthesiologist to administer general anesthesia (CPT code 00812).
Since an anesthesiologist’s involvement is not medically necessary for this low-risk routine procedure, the provider issues an ABN to inform the patient that Medicare may not cover this service. After the patient agrees to bear the financial responsibility, the provider appends the GA modifier with the anesthesia CPT code (00812-GA) on the claim.
Genetic Testing Despite Pre-Authorization Denial
Let us clear up your confusion with another example! Assume that a 52-year-old man with a history of hereditary colorectal cancer requests genetic testing to assess his own condition. The healthcare provider files a pre-authorization request for this test since Medicare covers it in some cases.
However, Medicare denies this request due to a lack of common colorectal cancer symptoms, including changes in bowel habits, blood in stool, rapid weight loss, and abdominal pain. In simple words, they consider this test to be medically unnecessary. Despite this denial, the patient decides to proceed with the examination to avoid potential risks.
Hence, the healthcare provider issues an ABN for non-coverage before performing this test. He applies modifier GA with the genomic sequence analysis (CPT code 81435-GA) when submitting the claim.
Medically Unnecessary Digital Breast Tomosynthesis (3D Mammography)
Suppose a 49-year-old woman goes to a radiologist for her annual breast checkup. Instead of her routine diagnostic mammogram (CPT code 77067), a standard 2D X-ray imaging, she requests 3D tomosynthesis (CPT code 77063).
However, Medicare only covers this service if it is medically necessary, that is, if a patient has dense breast tissue or is at high risk of breast cancer. Since she does not meet any of those conditions, the healthcare provider suggests a standard mammogram, but the patient is adamant about her request.
Therefore, the radiologist issues an ABN to the patient and applies modifier GA on the medical claim after performing this service.
Request for CIC Hearing Aids
Let’s consider an example for an item! A patient with mild hearing loss requests Completely in the Canal (CIC) hearing aids (HCPCS code V5258) because of their discreet design and custom fit. However, Medicare doesn’t cover hearing aids or even their fitting exams.
The supplier reports this issue to the patient via the Advance Beneficiary Notice. The patient, in turn, agrees to full financial responsibility. Hence, the supplier provides CIC hearing aids to the patient and applies modifier GA to the claim.
Modifier GA – Billing Guidelines
Understanding the appropriate use of modifier GA is necessary for maintaining compliance with Medicare’s rules. So, if you want to avoid payment disputes and don’t want to absorb the cost of a service or item, follow our billing guidelines for modifier GA.
Understand the Basic Requirements (Medical Necessity)
The most appropriate time to use modifier GA is when you are uncertain whether Medicare will accept or deny the claim due to medical necessity. Specifically, use this code with services or items that the federal insurance program is most likely to deny, such as experimental procedures or elective DMEs.
Review Medicare’s coverage policies, including local and national coverage determinations (LCD and NCD), to understand limitations and exclusions.
Issue an ABN Before Providing Any Service/Item
This is the most important factor. Always issue an Advance Beneficiary Notice (ABN) for non-coverage before initiating treatment or providing an item so that the beneficiary has enough time to make an informed decision. Also, keep these few things in mind:
- Use the official CMS-R-131 ABN form
- Include the following elements in your ABN
- A description of the service
- Potential reason for claim denial
- Estimated cost of the service
- Patient’s choice (accept or decline the service or item)
- Alternate options
In short, your ABN must include all the above-mentioned details so the patient understands their financial responsibility and alternate options.
Obtain Patient’s Signature
Want to avoid patient conflicts and payment disputes? Only proceed with treatment after obtaining the patient’s signature on the ABN. This will confirm that they understand Medicare’s requirements and are willing to pay for the service or item in case of denial.
Remember that healthcare providers also use ABN to inform patients about service exclusions — services or items that are never covered by Medicare. Patients don’t have to sign the form or choose any option in such cases.
Apply GA Modifier to Correct HCPCS or CPT Codes
Next, append this modifier to the correct service or item code. Keep in mind that while modifier GA is primarily used with HCPCS codes, you can apply it to the specific CPT codes as well in certain situations. For example, CPT code 77063.
Document Everything
Documentation is also quite important. Don’t forget to retain a copy of ABN once it is completed and signed.
Submit the Claim
Once everything is completed, review and modify the medical claim if necessary and submit it to Medicare.
Bill the Patient if Medicare Denies the Claim
If Medicare denies the claim with a GA modifier, you can transfer financial responsibility to the patient. Generate a detailed bill outlining the charger per issued ABN and submit it to Medicare’s beneficiary.
Avoid Basic Mistakes
Can the same rules be applied to dual-eligible beneficiaries (patients covered by both Medicare and Medicaid)? The answer is no! Healthcare providers cannot directly bill these patients, even if they expect Medicare to deny their claim.
Want to know why? Federal law protects such patients from being billed until both Medicare and Medicaid have reviewed and processed the claim. Therefore, if Medicare denies the claim with a GA modifier, it will automatically be transferred to Medicaid. But, if it is not automatically crossed over, you must manually submit the claim to Medicaid.
You should also avoid the following mistakes when using modifier GA:
- Do not place GA, GY, and GZ modifiers on the same claim line.
- Avoid using the GA modifier with the KX modifier.
Train Your Staff
To avoid unpleasant situations and rework, train your administrative and clinical staff on the proper use of modifier GA. Educate them about Medicare’s coverage policies, how to tackle dual eligible beneficiaries, and ABN rules, including the appropriate time to issue this notice to ensure 100% compliance.
Summary
There you have it! A simple explanation of modifier GA with the best tips for its appropriate use! In short, this modifier is used to notify Medicare that an ABN has been properly executed according to their policies. Simply put, you have delivered an ABN to the patient, and they have agreed to pay the estimated cost of a service or item if Medicare denies coverage due to a lack of medical necessity.
The use of this modifier is straightforward. You must adhere to Medicare’s policies to avoid financial losses. Remember that you can skip ABNs in emergency or urgent care situations.
Frequently Asked Questions
