Explanation of Modifiers for oral applicance billingIt is important to be familiar (especially when billing Medicare for custom made oral appliances for OSA) with the descriptions of the modifiers/codes GA, GZ, EY, KX, and A9270.
GA - Waiver of liability statement issued, as required by payer policy
Example of when to use: When the office HAS had the patient sign as ABN that they know Medicare likely will not pay for an item or service for whatever reason (i.e. patient does not meet coverage criteria but wants sleep appliance anyway), and patient had agreed to pay if Medicare does not.
GZ - Item or service expected to be denied as not reasonable and necessary
Example of when to use: When the office has NOT had the patient sign as ABN that they know Medicare likely will not pay for an item or service for whatever reason (meaning office would eat the cost if Medicare does not pay, cannot charge patient)
EY - No physician or other licensed health care provider order for this item or service
Example of when to use: When the office does NOT have a detailed written order (DWO) from physician on file for the sleep appliance.
KX - Requirements specified in the medical policy have been met
Example of when to use: When the office has all documentation requirements on file for sleep appliance.
A9270 - NON-COVERED ITEM OR SERVICE
Example of when to use: When an appliance is used that is not PDAC cleared for E0486. The Medicare LCD for Oral Appliance for OSA states: All custom fabricated mandibular advancement devices that have not received a written PDAC Verification Review must use HCPCS code A9270 (NON-COVERED ITEM OR SERVICE)