How to Use Modifiers to Indicate the Status of an Advanced Beneficiary Notice (ABN)

If a provider or supplier expects that the service or item furnished to the beneficiary may be considered unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used to inform the beneficiary of his or her financial liability, appeal rights and protections under the fee-for-service (FFS) Medicare program.

Providers should use the appropriate modifier when submitting such claims to indicate whether they have or do not have an ABN signed by the beneficiary.

Modifier Criteria

• HCPCS Modifier GZ must be used when physicians, practitioners or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary, and they do not have an ABN signed by the beneficiary
  • Note: Effective July 1, 2011, all claims line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. Please refer to MLN^® Matters article MM7228 (PDF) for further information
• HCPCS Modifier GA must be used when physicians, practitioners or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file

Note: All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with HCPCS Modifier GA or HCPCS modifier GZ.

For more information concerning ABNs and other types of notices, please refer to the Centers for Medicare & Medicaid Services’ (CMS) Beneficiary Notices Initiative page.

Updates to Manual Instructions for ABNs
For additional guidance regarding the use of the ABN and key updates, please refer to the Medicare Claims Processing Manual, 100-04, Chapter 30, Section 50 (PDF).