EM Coding Alert

Question: I am new to coding and I heard a fellow coder recently mention “getting an ABN” for a patient. I was too embarrassed to ask my colleagues what an ABN was, but could you explain it to me?

Nebraska Subscriber

Answer: An ABN, or advance beneficiary notice, is a form that you should get a patient to sign when your practice provides a service that Medicare might not cover completely, or at all. You can bill the patient for the service if you have a signed ABN. Without the ABN, you have no billing recourse if Medicare doesn’t pay for part or all of a patient’s service.

Also: Experts also recommend giving patients ABNs even when you know that Medicare will deny the service. (Medicare does not require an ABN if it explicitly excludes the service by statute.)

In these situations, the payer expects you to append one of the following modifiers to the CPT^® code you are reporting for the service:

• GA (Waiver of liability statement issued as required by payer policy, individual case): Use this modifier to indicate you’ve issued a mandatory ABN for a service as required, and it is on file. 
• GX (Notice of liability issued, voluntary under payer policy): Use this modifier when you give a patient an ABN for a service that Medicare never covers. In certain situations, you can also use this modifier in combination with modifier GY (see below). 
• GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit): Use this modifier to when Medicare excludes the item or service; or the item or service does not meet the definition of any Medicare benefit. In certain situations, you can also use this modifier in combination with modifier GX.
• GZ (Item or service expected to be denied as not reasonable and necessary): Use this modifier when you think Medicare will deny payment due to lack of medical necessity, and you didn’t issue an ABN.