Noncovered Charges for Outpatient Claims - JE Part A
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
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 |
| GK | Reasonable and Necessary Item/Service Associated with a -GA or GZ modifier | None | ABN required if -GA is used; no liability assumption since this modifier should not be used on institutional claims | Not used on institutional claims. Use -GA or -GZ modifier as appropriate instead | Institutional claims submitted using this modifier are returned to the provider |
| 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.
