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Family Practice Coding Alert

Reporting Noncovered Medicare Services

This spring, CMS deleted HCPCS modifier -GX (service not covered by Medicare). This modifier allowed family physicians and other providers to bill Medicare for non-covered services in order to get a denial, after which the practitioner could submit the charges to a secondary payer.

Two modifiers will take the place of modifier -GX. Modifier -GY will be used to report an item or service statutorily non-covered, and modifier -GZ will describe an item or service not reasonable and necessary. These new modifiers may be used beginning Jan. 1, 2002.

"Modifier -GX was appended to a service for any number of reasons," explains Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians. "The two new modifiers help to define those reasons."

Modifier -GY will be assigned for services that Medicare, by law, can't pay for. "For instance, Medicare is not allowed to cover preventive services [e.g., 99397, periodic preventive medicine, 65 years and older]," Moore says. "These aren't covered because laws governing Medicare say that, in general, only items or services rendered for the diagnosis or treatment of illness or injury may be paid. Preventive care doesn't fall into this category. The only exceptions to this are services specifically exempted by law -- like flu vaccines [e.g., 90658, influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use]."

On the other hand, coders should append modifier -GZ when national or local Medicare policy has excluded specific services as not reasonable or necessary. An example might be bone density scans (e.g., 76075, dual energy x-ray absorptiometry [DEXA], bone density study, one or more sites; axial skeleton [e.g. hips, pelvis, spine]), which are not covered unless certain prerequisites have been met.

With its implementation of -GY and -GZ, Medicare has added two new Q codes:

Q3015 -- item or service statutorily non-covered, including benefit category exclusion (used only when no specific code available)

Q3016 -- item or service not reasonable and necessary (used only when no specific code available)

These are "codes of last resort," Moore says, and would be assigned when no CPT or HCPCS code is available to describe the services rendered.

Additional information on these modifiers and Q codes can be found in Program Memorandum B-01-30, available on the CMS Web site (www.hcfa.gov).