RETIRED - Correct Coding - Submitting Oxygen Claims with Modifiers KX GA GY and GZ - JA DME

Joint DME MAC Article

It has recently come to the attention of the DME MACs that there are instances whereby a supplier possesses information that a beneficiary does not meet Medicare "Reasonable and Necessary" requirements for oxygen as specified in the Oxygen and Oxygen Equipment Local Coverage Determination (LCD L33797).

In order to expedite the adjudication of oxygen claims, the DME MACs will be adding the following modifiers to the Policy Specific Documentation Requirements section of the LCD L33797 Policy-related Article (A52514). These modifiers will indicate whether the applicable payment criteria are met (KX modifier), and provide additional information related to the coverage and/or liability (GA, GY and GZ modifiers) when the policy criteria are not met.

Effective for claims with Dates of Service (DOS) on or after 08/01/2018, the use of these modifiers is mandatory. Claim lines billed without a KX, GA, GY or GZ modifier will be rejected as missing information.

KX - Requirements specified in the medical policy have been met

The KX modifier must be appended to an oxygen or oxygen equipment claim when all the statutory and reasonable and necessary (R&N) requirements have been met. Suppliers are not required to secure all the required documentation prior to claim submission, however, appending the KX modifier to each of the oxygen codes billed serves as an attestation by the supplier that the requirements for its use have been met.

GA - Waiver of liability (expected to be denied as not reasonable and necessary, ABN on file)

When a Medicare claim denial is expected because an item or service does not meet the R&N criteria, the supplier must issue an ABN to the beneficiary before furnishing the item or service. When the beneficiary accepts financial responsibility, and signs a valid ABN, the supplier submits the claim to Medicare appending modifier GA to each corresponding HCPCS code. Modifier GA indicates that the supplier has a waiver of liability statement on file. Modifier GA must not be submitted if a valid ABN is not issued. Claims submitted with the GA modifier will receive a medical necessity denial holding the beneficiary liable.

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. Oxygen and oxygen equipment is covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)).  Claims for Oxygen equipment have additional statutory requirements pursuant to 42 CFR 410.38(g), and require a face-to-face evaluation and a specific written order prior to delivery for specified HCPCS codes. Claims submitted with the GY modifier will be denied as statutorily noncovered holding the beneficiary liable for the excluded services.

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

When a Medicare claim denial is expected because an item or service does not meet the R&N criteria, the supplier is expected to issue an ABN to the beneficiary. If the supplier chooses to accept liability for the expected denial, the supplier must append the GZ modifier to each corresponding HCPCS code. Modifier GZ indicates that the supplier does not have a waiver of liability statement on file. Claims submitted with the GZ modifier will receive a medical necessity denial holding the supplier liable.

Proper selection of the correct G modifier requires an assessment of the possible cause for a denial. Some criteria are based upon statutory requirements. Failure to meet a statutory requirement justifies the use of the GY modifier. When Reasonable and Necessary (R&N) criteria are not met, either the GA or GZ modifier is appropriate based upon Advance Beneficiary Notice of Noncoverage (ABN) status.

Additional information on the coverage, coding and documentation requirements for oxygen may be found in the Oxygen and Oxygen Equipment Local Coverage Determination (L33797) and related Policy Article (A52514) on the DME MAC web sites and the CMS Medicare Coverage Database.

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