RETIRED - Billing Reminder: Modifier Usage for Urological Supplies - Revised - JD DME

Article retired due to content incorporation into the applicable Local Coverage Determination or related Policy Article.

DME MAC Joint Publication

The Urological Supplies Local Coverage Determination (LCD) provides the use of modifiers with each submitted Healthcare Common Procedural Coding System (HCPCS) code. The use of the modifiers will indicate whether the applicable payment criteria are met (KX modifier), and provide information related to the coverage and/or liability (GA, GZ and GY modifiers) when the policy criteria are not met. This article reflects the appropriate use of each modifier to ensure correct use. Instructions for the GA and GZ modifiers were recently included in this LCD for proper consideration of usage (December 2013).  

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.

Urological supplies are payable under the Prosthetic Device benefit (Social Security Act Section 1861(s)(8)). Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in the affected beneficiary within 3 months. These requirements are statutory benefit requirements. When a beneficiary does not meet these requirements, the GY modifier must be used.

Aside from the above statutory coverage criteria, the remaining payment requirements are classified as R&N requirements. Examples (not all-inclusive) include utilization limits, medical necessity criteria for sterile kits, correct coding, etc. For those situations where R&N criteria are not met, either the GA or GZ modifier would be the appropriate choice depending upon ABN status.

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 a catheter code, an external urinary collection device or a supply item when all of the statutory and R&N requirements have been met. Suppliers are not required to secure all of the required documentation prior to claim submission, however, appending the KX modifier to each of the urological 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.  

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. 

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. For urological supplies, the prosthetic benefit requires that the beneficiary must have a permanent impairment of urination. In cases where the statutory criteria are not met, suppliers are required to code their claims for urological supplies with the GY modifier. Claims submitted with the GY modifier will be denied as statutorily noncovered holding the beneficiary liable for the excluded services.  Refer to the Urological Supplies LCD and related Policy Article for additional information about the payment rules, coding and documentation requirements.