The Practice Building Alliance™

Medical Insurance Techniques, Questions and Training

Pat Atanas CA Training

GA, GX, and GY Modifiers Used With Medicare

CALLER QUESTION: I got a quick question. Shouldn’t be too hard. It’s with the GA, GX, and GY modifiers that you use with Medicare.

I’ve been using the GA, but with the material I got from you, and reading, and also I had a seminar, I usually do the GA right away on the first visit, and it shows my initial exam, maintenance visits, that’s not being covered. Okay?

The webinar that I was listening to it kind of was saying that the GA is just for the maintenance visits. There’s a GX modifier for x-ray, and a GY for the exam. Is this correct?

John: Here’s the way it’s supposed to work, the way I understand it. The GA modifier is when you give the patient the advanced beneficiary notice. Actually, what the GA means is that, “I’ve determined that the patient might be at maximum improvement. I have given them the advanced beneficiary notice.

The patient has decided option one, 2, or 3, if they want me to bill, if they want the service, etc, etc. I understand Medicare may pay, they may not pay.” The neat thing about the GA is that when you give them the ADN, if Medicare does deny the service, it does allow you to then go ahead and collect from the patient.

Without the ADN, you cannot collect from the patient. So, what some chiros are doing is saying, “Well let me just go ahead and give out the ADN on the first visit,” which that is not when you’re supposed to give it out. The AT modifier means that the patient is under active treatment. They’re making functional improvement with my treatment. I can measure it. I can support it someway, somehow. It’s just like I told the last caller, that if all you did was use the subjective outcome assessments, that would help you a lot. Like if an Oswestry score goes from a 60 to a 40, then a 30, then a 20, that would be enough to substantiate an increase in function. But you have to use these objective measures.

So, the AT may say the patient is making an increase in function. The GA is like when you do an Oswestry; the patient says they’re feeling about the same on a follow-up re-exam, you use an Oswestry and the score is the same. You tell the patient, “You know, let me go into a gray area here, let me give you the ABN right now.” At that point, you give them the ABN, and you put the GA modifier. But if you think they might still make an increase in function, you’re going to put the AT and the end of it, as well. My understanding about the GX is that with chiropractic care it’s discriminatory coverage.

But if you want to let them know upfront that the x-ray and the exam might not be covered, you can go ahead and give them the ABN upfront, let them know the exams, x-rays, so on and so forth, that’s not covered. But you would put the GX modifier. And the difference between the GX and the GA is that one is statutorily required, that’s the GA, and one is not statutorily required. You don’t have to give the patient anything upfront in writing. I think as a chiropractor, that you definitely should have the talk with your Medicare patients, and let them know that Medicare doesn’t pay for all services. They don’t pay for x-rays, exams.

My mother went through this last year. She went through a different chiropractor and he was charging her the right way for exams and x-rays. She got offended. No other chiropractor she ever went to had ever charged her for this stuff before. So, she thought that he was doing something wrong. You have to really let people know, because they go to the Mayo Clinic or wherever they go, their doctor’s office, and they’re not asked to pay for exams and x-rays there, “So why is the chiropractor asking me to do that?”

So if you wanted to give them an ABN upfront for that, that’s not required. And that’s what the GX modifier is to be used for. It’s fairly new, but that’s my understanding, that it’s for non-statutorily required disclosures to the patient. Now what were the other modifiers I think you had there, a couple others?

Caller: GY, which I thought was for the examinations. 

John: GY means that it’s a non-covered service. So you put that there for that. And if it’s a physical therapy service, you would put a GP modifier indicating it’s physical therapy. And then GY, that it’s not statutorily covered.

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