Anesthesia Coding Alert

It's a fact of reimbursement life: Carriers don't always reimburse for anesthesia, especially for some monitored anesthesia-care (MAC) cases and other postoperative pain-management services. If a physician will provide services that the patient's carrier won't reimburse, it's important to have the patient sign a waiver or advance beneficiary notice (ABN) prior to the procedure stating that the patient will be responsible for payment. Knowing how to use ABNs and some new modifiers associated with them can make a big difference in a practice's bottom line.
 
CMS posted new ABN forms on its Web site late last year, along with instructions for their use. These simplified forms include one for general physician use, one designed for use with laboratory tests, and one that physicians can use to explain to patients which services Medicare never covers. Note: To view forms, visit hcfa.gov/medlearn/refabn.htm and go to "Medicare Announces New Patient Liability Notice."

It is important to clearly state on the ABN which healthcare items or services the physician does not expect Medicare to pay for and why. As the form's instructions state, "The items or services at issue must be described in sufficient detail so that the patient can understand precisely what items or services may not be furnished." The form also includes a box for the physician to complete stating the specific reason why he or she expects Medicare to deny payment.
 
Once the patient signs the ABN, it should be filed in the patient's medical record. A copy of the ABN does not need to be filed with the procedure claim, since the modifiers associated with the claim (described below) show that a waiver is on hand. "Since modifier -GA states that a waiver is on file, that's all that is necessary," explains Scott Groudine, MD, an Albany, NY, anesthesiologist. "Medicare wants to decrease paper billing because it increases their costs; it's much cheaper for them when electronic billing is done. You need to keep the ABN on file, but a paper claim does not have to follow."

When the anesthesia service is provided, it should be coded with the applicable modifiers to indicate that the provider knows Medicare will not reimburse for the service. Modifier -GA (waiver of liability statement on file) was the first modifier established for reporting non-reimbursable services. It is used when physicians, practitioners or suppliers want to indicate that they expect Medicare to deny a service as not medically necessary and the patient has signed an ABN.
 
Groudine offers the following example of when modifier -GA would be appropriate for anesthesiologists to use. A healthy patient undergoes a colonoscopy in an area where a local Medicare policy states that anesthesia for this procedure is not medically necessary unless complicated by diagnoses that this patient does not have. Since the practitioner expects Medicare to deny his service as medically unnecessary, he may want to have the patient sign an ABN and file his claim with modifier -GA, so he can collect funds from the patient after Medicare denies the claim. (The anesthesia code associated with the procedure would be 00810, anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum).
 
Two new Medicare modifiers associated with ABNs were first introduced in June 2001, and go into effect Jan. 1, 2002. They are:
 
Modifier -GY (non-covered service): This new modifier is used for items or services that are statutorily excluded or do not meet the definition of any Medicare benefit. "To me, this modifier is mainly for the secondary carrier," says Glenda D. Ballard, owner of Ballard Medical Management in Johnson City, Tenn. The firm handles anesthesia billing for solo practitioners and small group practices in several Southeastern states. "You have to get the denial from Medicare before you can file with the secondary carrier or write the service off," Ballard says. For example, if a pain-management specialist performs acupuncture on a patient, he knows the patient's secondary insurance will cover the service but that Medicare will not. The Medicare denial must be received before the secondary claim can be filed, so the service is coded as 97780 (acupuncture, one or more needles; without electrical stimulation) and appended with -GY for filing with Medicare.
 
Other procedures that could be coded with modifier -GY for anesthesia include elective cosmetic surgery and routine dental care, or any case where the surgeon performs a non-covered procedure. Groudine says that since these procedures are non-covered, there is not a Medicare fee schedule to guide the physician in deciding charges (as there is for -GA procedures). As such, the physician can charge his usual and customary rate for the anesthesia services.
 
Modifier -GZ (item or service not reasonable and necessary): This modifier must be used when physicians or practitioners want to indicate that they expect Medicare to deny an item or service as not reasonable and necessary. The big difference between this new modifier and modifier -GA is that in this case the practitioner does not have an ABN signed by the beneficiary. "I don't expect anesthesiologists to use this modifier much," Ballard predicts, "because anesthesiologists should never be doing something that's not reasonable or necessary. But there may be times when the physician doesn't see the patient far enough in advance to get a signed waiver before the procedure or when the patient isn't awake enough to sign the waiver. And it might apply to Category B services (such as 00100, anesthesia for procedures on salivary glands, including biopsy) that Medicare says don't need anesthesia but will pay for anyway if you have the right diagnosis to back it up."
 
Note: Modifier -GX (service not covered by Medicare) was deleted in 2002.

Modifiers -GY and -GZ should be used with the specific, appropriate HCPCS modifier when one is available, such as coding 00810-GA for a colonoscopy that does not meet the local medical review policies (LMRP) in that state as medically necessary. In case the carrier's computer won't accept the new modifiers, two temporary HCPCS codes have been established: Q3015 should be used if the carrier's computer won't accept the new -GY modifier, and Q3016 should be used in place of modifier -GZ; their descriptors are the same as for the modifiers. These new temporary codes will be deleted when permanent codes are adopted.
 
When there is no specific procedure code to describe services, a "not otherwise classified" code NOC must be used with the modifier along with a description of the service provided, Groudine says. Code A9270 (noncovered item or service) will no longer be accepted for services or items billed to carriers in this situation.

Having a waiver signed prior to providing MAC or postoperative pain-management services might be a "safe bet," Ballard says. "Getting a waiver couldn't hurt, but you also need to check into how the services are being coded and documented to help determine why they might be denied. Even with Category B services, Medicare will often pay for anesthesia if you have the right diagnosis associated with the service."
 
How often ABNs apply to anesthesia providers depends on the practice. "We never use them at the medical center, but it could be common in a practice that works in a facility doing lots of endoscopies where an LMRP makes it difficult to collect fees," Groudine explains.
 
"Obtaining a proper ABN involves time in talking to the patient and could cause them stress when they realize they could be liable for a charge they did not anticipate," he adds. "It is time consuming and cruel to do this unnecessarily, and also foolhardy because without justification the practitioner can open himself up to penalties. That's why it's so important to be sure that all claims with modifier -GA and other claims related to waivers are justified before filing them."