Monday, December 5, 2011

CLAIM INSTRUCTIONS WHEN A VALID ABN IS ON FILE - Modifier usage



When the previous instructions have been followed and a valid ABN on file, the following modifiers should be used to notify Medicare:

  • GA Use to indicate that an ABN was given as required by payer policy. A copy of the ABN does not have to be submitted but must be made available upon request.
  • GX Used to indicate that an ABN was given voluntarily under payer policy (UB-04) claims.
  • GZ Use when an item or service is expected to be denied as not reasonable and necessary and an ABN has not been signed. Effective July 1, 2011, all claim line items submitted with a GZ modifier will be denied automatically and will not be subject to complex medical review.
Note: For billing submitted on a UB-04 claim form, occurrence code 32 should be included on the claim to indicate the date the ABN was given.
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download