Reason Code 31241

Auto denial of claim line(s) submitted with a “GZ” modifier effective with July 1, 2011, dates of service for TOBs 12x, 13x, 14x, 22x, 23x, 32x, 33x, 34x, 71x, 72x, 73x, 74x, 75x, 76x, 77x, 81x, 82x, 83x and 85x.

This edit is an auto denial of claim lines with a GZ HCPCS modifier indicating that the provider expects medical necessity denial and a Advance Beneficiary Notice (ABN) was not provided to the patient. Medicare will adjudicate the service just like any other claim. If Medicare determines the service is not payable, the denial is under a “medical necessity.” The denial message indicates patient is not responsible for payment. If either beneficiary or provider requests a review, the modifier indicates ABN was not given, and this could assist an expedient review.

CMS Internet Only Manual (IOM), Publication 100-4, chapter 30 (PDF, 1.9 MB).



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