Gastroenterology Coding Alert

We’ve got one question for each coder — beginner, intermediate, and advanced.

Using advance beneficiary notices (ABNs) may seem straightforward, but that doesn’t mean every gastroen­terology practice is completing them properly. Whether you’re a veteran coder or you’re new to the field, you could probably benefit from a quick refresher.

Last month, Gastroenterology Coding Alert shared tips for coding colonoscopies at every level — beginner, intermediate, and advanced — and our readers responded so positively that they asked for more multi-level coding and billing tips. Therefore, the following FAQs about ABN usage are broken down by expertise level.

FAQ 1: Beginning Coders

Question: You discover your receptionist asks Medicare patients to sign ABNs for almost every service, whether or not you expect to collect. Is this an appropriate use of the form? And if not, when should you use an ABN?

Answer:  Although some practices do give patients ABNs for the majority of their services to cover them “just in case” Medicare is clear that this constitutes an inappropriate use of the form. “Providers and suppliers must be sure that there is a reasonable basis for noncoverage associated with the issuance of each ABN,” CMS says in its publication, “Advance Beneficiary Notice of Noncoverage.”

In reality, the first step to ABN usage is knowing when you should have the patient sign one, and when you shouldn’t. “A practice is not required to have a signed ABN for services that are never covered by Medicare,” said Laurie Troemel, CPC, CPMA, operations director with Medical Practice Management Services. “However, for those services that are normally a covered benefit but may not be covered due to medical necessity, frequency, etc., a signed ABN is required to obtain reimbursement from the beneficiary.”

You must issue the ABN when:

• You believe Medicare may not pay for an item or service;
• Medicare usually covers the item or service; or
• Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

Although not required, some experts do also recommend getting an ABN even when you know Medicare statutorily doesn’t cover a particular service because it engenders patient good will. This way, you notify the patient up-front that she will be responsible for a charge and how much she’ll expect to pay, ensuring that everyone is on the same page financially.

“ABNs used for non-covered services provide the documented proof that the patient made an informed choice to proceed with the service,” says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

You are also required to provide the patient with a copy of the ABN and the office should keep the original ABN on file. Be sure the language contained in the ABN is easily understood by the patient (don’t use CPT^® codes and diagnosis codes — instead, use a verbal description) and in terms the patient recognizes. Be sure to estimate the cost of the services that will be rendered as well. The patient must select an option and sign the ABN. In the case where the patient refuses to choose an option, the form must be annotated with this information. Often, these forms are incorrectly completed and are deemed invalid by Medicare.

FAQ 2: Intermediate Coders

Question: You give an ABN to a patient but the office manager says you should also use a modifier on the claim. Which modifiers apply?

Answer: Depending on which payment situation you expect, you’ll use a different one of Medicare’s “G” modifiers on your claim to explain to the insurer whether an ABN is on file, and if so, why. Append the appropriate G modifier, as follows, to give the payer more information:

• 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.

FAQ 3: Advanced Coders

Question: When should you collect from the patient for the noncovered service?

Answer: If the service is never covered by Medicare, you can collect from the patient on the date of service. However, you do not have the option to collect money from the beneficiary up-front if the patient signs the ABN because you suspect that the claim may be denied. Instead, in this case, you’ll wait for the denial from Medicare and then you’ll bill the patient.

In some cases, practices will erroneously charge patients up-front for services they assume won’t be covered due to what they’ve misinterpreted as non-coverage, and then the insurer will reimburse the charge after all. “In the event that Medicare pays all or part of the claim for which the beneficiary previously paid, CMS requires the provider refund the beneficiary for any overpayment,” Troemel says.

Therefore, you should first check whether a procedure is statutorily non-covered — in which case you can charge the patient up-front — and if that’s not the case, do not charge the patient until you get your remittance advice from the payer. The Medicare Physician Fee Schedule can identify whether a service is actively covered (Status A) or statutorily excluded (Status E or N), Pohlig advises.