When a CPT code alone doesn't provide enough information to accurately identify the entire service you provided, we can turn to modifiers to clarify, interpret and provide more information than we can capture solely in CPT or HCPCS codes. Here's a brief refresher on the proper use of the GA and —59 modifiers.

• GA modifier. Use modifier GA when you expect Medicare to deny a service as not medically necessary and when an appropriate and properly executed advanced beneficiary notice (ABN) has been obtained from the patient and is on file. ABNs cannot be used routinely without an appropriate reason. Use ABNs when a service may not be covered, based on medical necessity determined by diagnosis code or based on frequency parameters (it's only been 6 years since a patient's last screening colonoscopy, a service that's covered every 10 years, for example). When a patient executes an ABN, he must know before the service that the service may not be covered, the reason the service may not be covered and the amount that he'll be responsible for if it's not covered.

If you've obtained an appropriate ABN, but you haven't attached a GA modifier to the claim, Medicare may deny the claim as not medically necessary and you'd have to contractually adjust off the service.

Note that if a service may be considered not medically necessary, but you didn't acquire an appropriate ABN, attach the modifier GZ. This potentially will result in a denial and will need to be contractually adjusted, but it does make it clear to Medicare that you're not trying to bill and recoup funds for services that aren't medically necessary. Warning bells should ring if you're using the GZ modifier with any frequency, as all of these services indicate an opportunity in which you should have obtained an ABN.

• Modifier 59. Use this modifier for accurate and appropriate reimbursement when 2 services that normally would be bundled together are in a particular circumstance distinct and separate. For example, take a biopsy and an excision. These are bundled so that you're never paid separately for them. But if you perform an excision of a separate lesion, you'd attach —59 to indicate that the second excision is distinct and separate.

The Correct Coding Initiative (CCI) edits identify many code pairs that normally aren't billed together or shouldn't be billed together. Some of these edits identify codes that can never be billed together in any circumstance, but some of the code pairs when certain situations occur can be billed together and the modifier —59 must be attached to allow for reimbursement. Key factors to identify if the service is distinct and separate include a different incision or a different excision, a different body area or a different time of day. The risk of modifier —59 is overuse or abuse in an effort to receive payment for services that should be bundled together and not paid separately.

ital additions
Modifiers are crucial to accurately capturing the specificity of surgical services and providing additional information that is often necessary. They can cover a wide range of information, from the status of the patient, the type of provider, events in a surgical period, anatomical sites or separate and significant services.