Modifiers

Table of Contents

• General Modifier Information
• CPT Modifiers (Used in Medicare Part B)
• HCPCS Modifiers
• ABN Modifiers GA, GX, GY and GZ
• Ambulance Origin and Destination Modifiers

[Return to Top]

General Modifier Information

Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code.

Modifiers may be used to indicate:

• a service or procedure has both a professional and technical component,
• a service or procedure was performed by more than one physician,
• a service or procedure has been increased or reduced,
• only part of a service was performed,
• an additional service was performed,
• a bilateral procedure was performed more than once or
• unusual events occurred.

[Return to Top]

CPT Modifiers (Used in Medicare Part B)

[Return to Top]

HCPCS Modifiers

Related Content

• CMS MLN Fact Sheet: Proper Use of Modifiers 59 & –X{EPSU};
• CMS Billing and Coding Article A55932: JW and JZ Modifier Billing Guidelines
• Drugs and Biologicals

[Return to Top]

ABN Modifiers GA, GX, GY and GZ

These modifiers can be used by physicians, practitioners or suppliers to indicate services that are expected to be denied because of lack of medical necessity or statutory exclusion, and those that do not meet the definition of any Medicare benefit. Below are the definitions of each modifier and their appropriate applications.

Reminder: Routine or blanket ABNs are usually not permitted. An ABN should only be given to a Medicare beneficiary when the provider has reason to expect that Medicare will deny payment for some or all of the services. That reason should be listed on the ABN.

For more information on ABNs, you may refer to the CMS website Advance Beneficiary Notice of Noncoverage.

GA Modifier: Waiver of liability statement issued as required by payer policy

Used to report when a mandatory ABN was issued to a beneficiary for a covered service that is not likely to be covered by Medicare due to medical necessity. This modifier is frequently used by chiropractors to indicate that spinal manipulation is being provided as maintenance care. Medicare does not reimburse for spinal manipulation that is performed as maintenance care or does not meet for medical necessity.

Facts

• May not be submitted with services that are statutorily excluded. Refer to HCPCS modifier GY for these services.
• May not be submitted, on the same detail line, with chiropractic modifier AT. Effective for dates of service on and after 11/1/2015, services submitted with both modifiers, on the same detail line, will be rejected. Rejected claims must be resubmitted as new claims.
• Indicates the expected denial that an item or service is not reasonable and necessary
• The most common example of these situations would be services adjudicated under an LCD.
• The presence or absence of this modifier does not influence Medicare's determination for payment.
• It is appropriate to report this modifier when the beneficiary refuses to sign the ABN.
• If Medicare determines that the service is not payable, the claim denial is under a “medical necessity denial.”
• Medicare will use claim adjustment reason code 50 (these are noncovered services because this is not deemed a “medical necessity” by the payer) when denying lines due to the presence of the GA modifier.
• Should not be used on a routine basis for all services performed by a provider/supplier.
• Medicare will use claim adjustment reason code 50 (these are noncovered services because this is not deemed a “medical necessity” by the payer) when denying lines due to the presence of the GA modifier.

GX Modifier: Notice of liability issued, voluntary under payer policy

Used to report when a voluntary ABN was issued for a service. The GX modifier would be appended in addition to the GY modifier. The modifier GX was created to report on a claim when a provider has issued an ABN voluntarily for noncovered services.

Facts

• You may use the GX modifier to provide beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute, and in these cases, you may report it on the same line as certain other liability-related modifiers. Please note that the GX modifier must be submitted with noncovered charges only, and your A/B MAC will deny the claim as a beneficiary liability.
• Medicare systems will recognize and allow the GX modifier on claims, but will return your claim if the GX modifier is used on any line reporting covered charges.
• Submit this modifier if you have voluntarily obtained a valid ABN. This includes ABNs obtained for services that are “statutorily denied,” such as physical therapy services provided by chiropractors. You may, but are not required to, ask patients to sign ABNs for services that are “statutorily denied.”
• Part B services will automatically be denied when submitted with HCPCS modifier GX.
• Part A services will automatically be denied when submitted with HCPCS modifier GX.
• You may report this modifier in addition to HCPCS modifiers GY and TS.
• Can be combined with modifiers GY and TS (to indicate beneficiary liability) but not EY, GA, GL, GZ, KB, QL or TQ.
• Lines will automatically deny (using claim adjustment reason code 50) submitted with the GX modifier and noncovered charges, and will assign beneficiary liability to claims automatically denied when the GX modifier is present.

GY Modifier: Notice of liability not issued, not required under payer policy

Should be used on all services that are statutorily excluded or do not meet the definition of any Medicare benefit. Providers do not have to submit claims for noncovered services (e.g., massage, therapy, x-ray, etc.) unless the beneficiary requests claims are submitted, or if a denial is needed for secondary insurance claims processing. Providers may voluntarily use an ABN form to advise beneficiaries of services that Medicare does not cover under any circumstances.

Facts

• Services provided under statutory exclusion from the Medicare Program; the claim would deny whether or not the modifier is present on the claim.
• It is not necessary to provide the patient with an ABN for these situations.
• Modifier GY will cause the claim to deny with the patient liable for the charges.
• Should not use on bundled procedures.
• Should not use on add-on codes.
• Providers that submit claims with the intent of denial for supplemental insurance are not able to submit a routine diagnosis for denial unless all of the reported diagnosis codes are routine noncovered. A combination of the routine diagnosis and the use of the GY modifier will be required for denial.

GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary

Used when a provider does not expect a service to be covered by Medicare, and does not have a valid ABN on file. Beneficiaries are not liable for payment of services, when they were not notified prior to the services being rendered that the service would not be covered by Medicare due to medical necessity.

Facts

• This modifier is an informational modifier only.
• Medicare will adjudicate the service just like any other claim.
• If Medicare determines that the service is not payable, denial is under a “medical necessity.” The denial message will indicate that the patient is not responsible for payment.
• If either the beneficiary or provider requests a review, the modifier tells us that an ABN was not given, and this could help in completing the review quickly.
• Line items denied due to the presence of the GZ modifier will reflect a CARC of 50 (these services are noncovered services because this is not deemed a “medical necessity” by the payer) and a Group Code of CO to show provider/supplier liability.

Related Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12 ‘Physicians/Nonphysician Practitioners’
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50 
• CMS MLN Educational Tool: Advance Beneficiary Notice of Non-Coverage Interactive Tutorial

[Return to Top]

Ambulance Origin and Destination Modifiers

The following alpha values must be used in combinations of two to create a two- position ambulance origin/destination modifier. The modifier must indicate both the origin and destination of the run and must be entered for every ambulance trip.

Example: Modifier RH would be used for an ambulance trip from the residence to the hospital.

• The first position alpha value = origin of service.
• The second position alpha value = destination of service

Revised 10/16/2024