GA Modifier

GA Modifier Definition, Billing Guidelines, Reimbursement & Examples

GA Modifier is applied for service when a waiver of liability statement is issued as required by payer policy, individual case. The physician provides a service to the patient and is more likely to deny by the insurance. He asks to sign the patient on advance beneficiary notice (ABN) before the procedure; if insurance does not pay for the service, the patient will be responsible for the payment. ABN may not need the insurance at the time of submission of the claim but is available upon request. Radiology, laboratory, and evaluation management services are more like to perform multiple times in one day. In these scenarios, GA Modifier may require reporting with the procedure.

GA Modifier Definition

GA Modifier usually appends with the service when it is not medically necessary and reasonable.

The patient is responsible for the payment and does not have any other insurance.

ABN does issue at the time of service. If the patient has secondary insurance, it will automatically deny by Medicare and bills secondary insurance.

Evaluation and management (E/M) codes accept GA Modifier and are medically appropriate.

Only one E/M service can perform on the same date for one reason.

Another physician can report the other service if the patient encounters the same reason on the same day with modifier GA when ABN is not issued.

Medical documentation must support the medical necessity of the repeated service. It may deny by the insurance or third party. Check the appropriate guidelines for the repeated services.  

Modifier GA is applied for service when a waiver of liability statement is issued as required by payer policy, individual case.

modifier ga
Modifier GA Description

Reimbursement 

Modifier GA indicates service was not medically necessary and appropriate.

It may deny by the insurance and liability assigned to the beneficiary when a person has secondary insurance and will reimburse the service if covered. GA Modifier must use with non-covered charges.

GA Modifier Coding Guidelines

Documentation does not support the medical necessity of service or is medically inappropriate.

The patient condition reflects the significance of the service.  

Service does not meet the criteria for medical appropriateness of service.

It must indicate Modifier GA and bills on a separate line. For example, if any service requires a specific diagnosis for reimbursement.

The service lists it as a non-covered diagnosis.

ABN does sign by the patient. In this case, liability assigns to the patient instead of the provider.

Radiology services require a specific diagnosis code for the services.

The list of DX codes is available by CMS according to their respective LCD/NCD.

For instance, the patient comes to a physician and asks for CT Chest without any signs and symptoms.

The physician performs the CT with ABN. The Study shows unremarkable CT of the chest.

The doctor expects that service may deny by insurance. GA Modifier attaches to the claim to represent service as the patient’s liability.

Modifier GA does not allow the bill along with modifier GX, GY, and GZ on the same line.

GA Modifier is applicable with surgical and laboratory procedures as well.  

Claim reports with the separate line when modifier GA is attached.

Two units of procedure shall deny by the insurance, like 71046×2. It appropriates to reports such as:

E/M service (99201-99499) appropriates to report with modifier GZ.

The patient presents to the office for a steroid injection. He has another visit by the same physician or with the same specialty on the same day.

ABN issued by the patient. Medicare does not pay for the same reason of encounter on the same day.

It reports with modifier GZ for two units of service like 99203-GA.

The service performs without any specific procedure code. Instead, it reports with GA Modifier If ABN has already issues to the physician.

When To Use GA Modifier

Modifier GA bills if the physician is confident that service may deny by Medicare.

Advance beneficiary notice issues by the physician before services render to the patient.

If Medicare denies this service, the beneficiary will be responsible for payment.

For instance, the patient wants to repeat the service by another physician for a second opinion.

The service seems unnecessary to the physician. Modifier 77 attach to unbundle the service, and modifier GA indicates that Medicare denies paying for this service.

Patients are responsible for paying for the services furnished by the physician.

GA Modifier Examples

The following are the examples of Modifier GA when this service bills:

Example 1

58 y/o male with a PMH of HTN, HLD, hypothyroidism presents to the hospital outpatient setting because of a headache and high blood pressure before arrival.

The patient lays down in bed at 10 pm and begins having a gradual onset pulsating frontal and occipital headache.

He reports that the pain was very severe. His headaches are usually associated with HTN.

The blood pressure shows a value of 210/100 and denies associated dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, abdominal pain, nausea/vomiting.

The physician ordered a series of diagnostic tests CT, MRI, and EKG. EKG was independently interpreted and reviewed by the doctor.

EKG exceeds the limits of unit performance in one day. ABN issued by the patient.

The radiologist bills the extra unit with modifier GA, and the patient is responsible for the service payment.

Example 2

A 51-year-old-female presents to the emergency with syncope. The patient applies a nicotine patch earlier.

The patient had a brief episode of feeling hot, numbness, tingliness in her b/l hands, “gas discomfort” in her stomach, and headache.

When she tried to get up, she lost consciousness(witnessed by her partner, who I spoke to for more history).

Partner states she was only out for a few seconds before perking up to routine. Pt states she has had episodes like this in the past but several years ago.

No known cardiac history. Physicians plan to order CBC, CMP, mg, phos, trop, EKG, Tylenol, Pepcid, and Zofran.

CMP repeated twice in one day and expected to deny by the insurance.

Pathology asks the patient for ABN. Laboratory service reports with modifier GA.

The radiologist bills the extra unit with modifier GA, and the patient is responsible for the service payment.

EKG: Normal sinus rhythm. 70 bpm. No ST elevation or T wave inversions.

CXR: My interpretation showed no acute abnormalities.

Example 3

A 36-year-old male presents to the emergency department with PMH HTN, HLD, Afib (on eliquis), Mitral valve replacement, and gout, contributing to the office today for dark blood stools for two days.

He states that he started having diarrhea yesterday and has had 4 BM in the past two days.

The patient denies nausea, vomiting, CP, SOB, dizziness, fevers, chills, and took eliquis this morning.

The physician also notes worsening bilateral lower extremity edema, for which he takes Lasix.

In addition, he took Indomethacin for four days for a presumed gout flare.

The colonoscopy was done three years ago and found benign polyp but otherwise WNL.

Physician plan to admit and Plan Labs, EKG, CT abdomen, and Pelvis, and prescribed Medicine.

EKG exceeds the limits of unit performance in one day. ABN issued by the patient.

The radiologist bills the extra unit with GA Modifier, and the patient is responsible for the service payment.

Example 4

70-year-old female presents to ED with a history of HLD and is presenting to the OPD for substernal chest pain.

The patient worked out daily, was a very healthy, active senior, lived at home, and worked out today.

After the workout, she took a sip of water, and she had substernal chest pain, none radiating, associated with weakness.

However, Gatorate helped with the substernal chest pain. She had no chest pain shortly after.

However, her trainer told her to see a provider. She went to urgent care with asymptomatic resolved chest pain; they sent her over here because she had a family history of MI in her family.

Her brother died of MI at age 48 EKG without ischemic changes. Low suspicion for ACS. HEART score 3.

EKG exceeds the limits of unit performance in one day.

ABN issued by the patient. The radiologist bills the extra unit with GA Modifier, and the patient is responsible for the service payment.

Example 5

38-year-old female past medical history of chronic gastritis diagnosed on endoscopic two weeks ago presenting with one month of on and off palpitations and lightheadedness.

The patient states that she has been feeling off for the last month and describes her symptoms as when she wakes up in the morning and feels fogginess has bouts of palpitations with associated lightheadedness without syncope.

The patient cannot pinpoint a trigger and states her symptoms resolve on their own.

Palpitations frequently happen everywhere in the body.

The patient endorses that she has a healthy diet and does not do any narcotics drink alcohol or smoke.

The patient otherwise denies fevers, chills, syncope, headaches, neck pain, chest pain, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, and constipation.

The physician decided to obtain EKG labs and chest x-ray reassess. EKG exceeds the limits of unit performance in one day.

ABN issued by the patient. The radiologist bills the extra unit with modifier GA, and the patient is responsible for the service payment.

EKG normal sinus rhythm at 74 bpm with a QTC of 426, no ST elevations or depressions.

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