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Modifier GA Fact Sheet

Definition

  • The provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient.

Example: The medical reason for performing this test does not meet medical necessity and the provider is expecting a denial. Therefore, prior to performing the service the beneficiary was given an ABN that explained that the claim would be denied.

Modifier GA Sample

Appropriate Usage

  • Indicates the expected denial that an item or service is not reasonable and necessary
  • The most common example of these situations would be services adjudicated under a Local Coverage Decision (LCD).
  • The presence or absence of this modifier does not influence Medicare's determination for payment.
  • It is appropriate to report this modifier when the beneficiary refuses to sign the ABN.
  • If Medicare determines that the service is not payable, the claim denial is under a "medical necessity denial."

Inappropriate Usage

  • When the provider/supplier has no expectation that an item or service will be denied.
  • On a routine basis for all services performed by a provider/supplier

Page Last Updated: Wednesday, 26-Nov-2014 12:30:22 CST