Noncovered Charges for Outpatient Claims

Providers are required to determine if the services they are providing a beneficiary meet medical necessity criteria under the Medicare program. At times providers may choose to still provide a service they feel doesn't meet medical necessity, which would be considered the liability of the provider and nothing can be billed to the beneficiary. If the provider feels the service doesn't meet medical necessity and isn't planning to assume liability for these charges it is the providers responsibility to inform the beneficiary prior to providing the service by issuing an Advance Beneficiary Notice of Noncoverage (ABN).

Billing with an ABN

Providers are required to use the appropriate ABN form as specified in the above references ABN, ABN-L or ABN-G. Since 3/1/09, providers are to only use the revised ABN which replaced the ABN-L or ABN-G and NEMB forms per CR6136 9/5/08. There is also an additional optional form providers may use to inform the beneficiary of potential liability e.g. statutory exclusions, which is called the Notices of Exclusions From Medicare Benefits (NEMB) form, but it is not mandatory to use this form.

When providers submit claims where the ABN form has been issued to the beneficiary, you are required to add the 32-occurrence code to reflect the date of service (DOS) of the lines with the GA modifier. If multiple ABNs have been issued with different DOS providers would be required to submit a 32-occurrence code for each DOS coinciding with all the ABNs given along with the appropriate modifiers as listed in the table below.

Definition for Noncovered Charge Modifiers for Outpatient Claims

Modifier Description HCPCS Coverage/Payment Admin. Instruction Notice Requirement/Liability Billing Use Payment Result
EY No Physician or other licensed health care provider order for this item or service   None, cannot be used when HHABN or ANB is required, recommend documenting records; liability is provider unless other modifiers are used (GL, GY or TS) To signify a line-item should not receive payment when Medicare requires orders to support delivery of a item or service (i.e., TOBs 21x, 22x, 32x, 33x, 34x, 74x, 75x, 76x, 81x, 82x, 85x) When orders are required, line item is submitted as noncovered and services will be denied provider liable
GA Waiver of Liability Statement on file None ABN required; beneficiary liable To signify a line item is linked to an ABN when charges both related to and not related to an ABN must be submitted on the same claim Line item must be submitted as covered; Medicare makes a determination for payment
GL Medically Unnecessary upgrade provided instead of standard Item, no charge, no ABN None Can't be used if ABN/HHABN is required, COPs may require notice, recommend documenting records; beneficiary liable Use only with durable medical equipment (DME) items billed to the RHHIs (TOBs: 32x, 33x, 34x) Lines submitted as noncovered and will be denied beneficiary liable
GY Item or service Statutorily Excluded or does not meet the definition of any Medicare Benefit Noncovered by Medicare Statute (ex. Service not part of recognized Medicare benefit) Optional notice only, unless required by COPs; beneficiary liable Use on all types of line items on provider claims Lines submitted as noncovered and will be denied beneficiary liable
GZ Item or service expected to be denied as not reasonable and necessary None Cannot be used when ABN or HHABN is required, recommend documenting records; provider liable Indicates ABN was not issued to the beneficiary and signifies that the provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy. As of July 1, 2011 claims with GZ modifier will deny automatically as provider liable. Claims will not be reviewed by Medical Review to determine medical necessity.
QL Patient pronounced dead after ambulance called None None, recommend documenting records; provider liable Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 85x) Mileage lines submitted as noncovered and will be denied provider liable; base rate line submitted as covered
TS Follow-up service Not payable by Medicare No notice requirement, unless COPs require, recommend documenting records; beneficiary liable Use on all types of provider claims when services are billed as noncovered for reasons other than can be established with other coding/modifiers (i.e., GY) when the beneficiary is liable for other documented reasons Lines submitted as noncovered and will be denied beneficiary liable

 

Below are uses of line-Item modifiers for claims that have covered and noncovered charges on same claim.

Source of Modifier List Modifiers Claims Processing Instructions
HCPCS Modifiers Not Covered or Not Payable by Medicare by administrative instruction within definition A1 through A9, GY, GZ, H9, HA-HZ, SA-SE, SH, SJ, SK, SL, ST, SU, SV, TD -TH, TJ -TN, TP -TW, U1-U9, UA-UD FISS will deny all line items on all TOBs using these modifiers as part of processing the claim. Provider or beneficiary liability as listed in chart above
CPT/HCPCS Modifiers Permitted on OPPS Claims CPT: 25, 27, 50, 52, 58, 59, 73, 74, 76, 77, 78, 79, 91

HCPCS: CA, E1-E4, FA, F1-F9, GA, GG, GH, GY, GZ, LC, LD, LT, QM, QN, RC, RT, TA, T1-T9
FISS will access these modifiers for processing on OPPS claims with TOB 12x, 13x and 14x as identified in chart above
Modifiers used in billing Ambulance noncovered charges GY, QL, QM, or QN Applicable TOBs for ambulance billing: 12x, 13x, 22x, 23x, and 85x
Specific HCPCS Modifiers to consider related to noncovered charges or ABNs EY, GA, GK, GL, GY, GZ, KB, & TS FISS will accept these modifiers for processing as identified in chart above

 

When providers are submitting claims with individual or multiple line items that are noncovered either by Statutory Exclusion, National Coverage Determination (NCD), or Local Coverage Determination (LCD) you will need to submit claims with the appropriate modifiers, charges in covered/noncovered based off the modifier when submitting claims to Noridian. Please refer to the table above for the modifier description to determine liability and if the charges should be in covered or noncovered.

As a reminder to the providers you are required to use detailed HCPC codes to identify the noncovered service provided. If there isn't a specific HCPC code to detail the service you are allowed to submit the A9270 (noncovered item or service) along with the appropriate modifier to deny the line item as beneficiary or provider liable (e.g., GL, GY, TS)

When providers are submitting noncovered charges on a claim where the 20 or 21 condition code is required it's up to the provider to determine which is condition code is appropriate.

  • 20 condition code - reflects that the beneficiary is requesting a demand bill so the claim will have an additional documentation request (ADR) so Noridian can determine if the service meets medical necessity or is a noncovered service
  • 21 condition code - reflects that the provider is billing this service as noncovered to receive a denial by Medicare, have the noncovered charges processed by a supplemental insurance plan etc.

Resources

 

Last Updated Tue, 11 Feb 2020 12:51:38 +0000