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Contractors to deny claim line items with -GZ modifier

HIM Connection, February 15, 2011

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by Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc

In two recently issued transmittals, CMS ordered all contractors – MACs, CERTs, RACs, PSCs and ZPICs – to automatically deny all claim line items with the -GZ modifier attached. Specifically, contractors are not to perform complex medical review on those line items that are submitted with a -GZ modifier.

Although the transmittals focused primarily on applying the new edit to the claims of physicians, other practitioners and suppliers, institutional providers have used the -GZ modifier for some time to identify certain types of non-covered services. These two recent transmittals are just part of CMS’ continuing efforts to clarify the definition, use, and operational impact of certain modifiers intended to identify what the provider (professional, institutional, or supplier) believes to be non-covered services.

According to CMS, modifier -GZ must be used when a provider expects Medicare to deny an item or service as not reasonable and necessary, but the provider has not provided the required notice (an Advance Beneficiary Notification [ABN]) to the beneficiary prior to furnishing that item or service. Medicare expects providers to be familiar with applicable Medicare coverage policies, and, thus, able to make such determinations.

When an item or service is expected to be denied for lack of medical necessity, CMS generally requires providers to notify the beneficiary of his or her financial responsibility for that service, prior to its performance, in order to shift the financial responsibility from the provider to the beneficiary.

Read more on the MedicareFind blog.

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