HCPCS Modifier GZ Modifier | Description & Billing Guidelines

HCPCS Modifier GZ is used to indicate items or services expected to be denied by Medicare as not meeting medical necessity requirements, but the provider does not present the patient with an ABN and may not bill the patient for denied charges but can request a review.

What Is HCPCS Modifier GZ?

The Healthcare Common Procedure Coding System (HCPCS) Modifier GZ is a modifier that is used to identify items or services that the provider believes will not meet the requirements of Medicare for medical necessity.

The provider expects Medicare to deny reimbursement for the item or service. However, in the absence of an Advance Beneficiary Notice (ABN), the provider does not present the patient with any notice of the potential denial.

This means that the provider may not bill the patient for the denied charges, but they can request a review of the denial if they feel it was unjustified.

NOTE: The GZ Modifier does not guarantee that Medicare will not pay for the item or service. However, it serves as a flag to indicate that the provider believes it may not meet the requirements for medical necessity.

Description

The official HCPCS description of the GZ modifier is: “Item or service expected to be denied as not reasonable and necessary.”

How To Use The GZ Modifier

(HCPCS) Modifier GZ can be used for providers who expect Medicare to deny reimbursement for an item or service because it is not considered medically necessary.

The provider needs to append the GZ modifier to the appropriate code to indicate this expectation to Medicare.

The purpose of this modifier is to inform Medicare of the provider’s belief that the item or service in question may not meet the requirements for medical necessity and, thus, may not be eligible for reimbursement.

The GZ modifier does not automatically guarantee that Medicare will deny reimbursement for the item or service. However, it does serve as a flag to Medicare to review the item or service in question and decide based on the requirements for medical necessity.

When the GZ modifier is used, the provider is not required to provide the patient with an Advance Beneficiary Notice (ABN).

An ABN is a document given to the patient by the provider when there is a possibility that Medicare may not cover a specific item or service.

The provider may not bill the patient for the denied charges by not providing the patient with an ABN. However, if the provider feels that the denial was unjustified, they can request a review of the decision made by Medicare.