Awareness : OBC Tips

How to Use Modifiers to Indicate the Status of an ABN

If a provider anticipates that the service or item furnished to the patient may be considered unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used to inform the patient of his or her financial liability, appeal rights, and protections under the fee-for-service (FFS) Medicare program.

Providers should use the appropriate modifier when submitting such claims to indicate whether they have or do not have an ABN signed by the beneficiary.

Modifier criteria:

  • Modifier GZ: must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary, and they do not have an ABN signed by the beneficiary. For additional information, please refer to the MLN® Matters article MM7228.
  • Modifier GA: must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file.

Note: All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with modifier GA or modifier GZ.

For more information concerning ABNs and other types of notices, please refer to the Centers for Medicare & Medicaid Services’ (CMS) Beneficiary Notices Initiative page.

For additional guidance regarding the use of the ABN and key updates, please refer to the Medicare Claims Processing Manual, 100-04, Chapter 30, Section 50. page.