Article Detail - JA DME

Suppliers are reminded that enteral nutrition and parenteral nutrition claims (nutrition, pump, and supplies) submitted without a KX, GA, GY, or GZ modifier will be rejected as missing information for dates of service on or after July 2, 2023.

The proper use of modifiers indicates whether the beneficiary meets reasonable and necessary requirements in a Local Coverage Determination (LCD). The KX modifier indicates the applicable payment criteria are met, and provides additional information related to the coverage and/or liability. The GA, GY, and GZ modifiers indicate policy criteria are not met. The use of one of these modifiers is mandatory. Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information. The KX modifier must not be appended on the same line as the GA, GY, or GZ modifier.

KX - The requirements specified in the medical policy have been met

The KX modifier must be appended to enteral and parenteral nutrition, pump, and supply claims when all reasonable and necessary and statutory requirements are met. Suppliers are not required to secure all the required documentation prior to claim submission, however, appending the KX modifier to each of the nutrition codes billed serves as an attestation by the supplier that the requirements for its use have been met.

GA - Waiver of liability (item/service expected to be denied as not reasonable and necessary, Advance Beneficiary Notice of Noncoverage (ABN) on file)

The GA modifier indicates that the supplier has a waiver of liability statement on file. When claim denials are expected because the reasonable and necessary criteria are not met, an ABN must be issued to the beneficiary before an item is dispensed. When the beneficiary signs a valid ABN, they accept financial responsibility. The supplier may then submit a claim to Medicare with the GA modifier appended to each corresponding HCPCS code. If the issued ABN is not valid, the GA modifier must not be appended. Claims submitted with the GA modifier will receive a beneficiary liable medical necessity denial.

GZ - Item or service not reasonable and necessary (expected to be denied as not reasonable and necessary, no ABN on file)

When an item does not meet the reasonable and necessary criteria and a denial is expected, the supplier must issue an ABN to the beneficiary to transfer liability. The GZ modifier indicates that the supplier does not have a waiver of liability statement (ABN) on file. Claims submitted with the GZ modifier will receive a supplier liable medical necessity denial. The GZ modifier must be appended to each corresponding HCPCS code if an ABN is deemed invalid or the supplier chooses to accept liability for the expected denial.

GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit

The GY modifier indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Claims submitted with the GY modifier will be denied as statutorily noncovered holding the beneficiary liable for the excluded services.

Suppliers are expected to know and understand policy requirements and append the correct modifiers. When reasonable and necessary criteria are not met, either the GA or GZ modifier is appropriate based on the ABN status. Some criteria are based upon statutory requirements. Failure to meet a statutory requirement justifies the use of the GY modifier.

Additional information on the coverage, coding, and documentation requirements can be found in the Local Coverage Determination and related Policy Article. Refer to the Advance Beneficiary Notice of Noncoverage (ABN) webpage on the Noridian Medicare website for liability limitations.