Gastroenterology Coding Alert

CMS has unveiled its new advance beneficiary notice (ABN), and even though the hard deadline is several months away, you should take steps now to put it into practice.

Good news: The new ABN not only replaces the previous ABN-G (for physicians) but also incorporates the notice of exclusion from Medicare benefits (NEMB) form. CMS expects this new, combined form to "eliminate any widespread need for the NEMB in voluntary notification situations," according to the new ABN Form Instructions document.

The NEMB's previous purpose: In case you weren't familiar with exactly when you were supposed to use the ABN rather than the NEMB, keep in mind that in the past, ABNs were only for procedures that Medicare might not cover but didn't apply to procedures that were statutorily excluded from Medicare benefits. That was where the NEMB came in -- you were able to use it for services such as cosmetic surgery, which Medicare never covered.

Now CMS will accept the new ABN form for either purpose, noting in its ABN Instructions that "the revised version of the ABN may also be used to provide voluntary notification of financial liability."

Don't worry: Although Medicare carriers began accepting the new ABN form as of March 3, CMS has implemented a six-month transition period. Therefore, you aren't required to submit the new form until Sept. 1.

Although the ABN form has changed, many of the previous ABN "best practices" remain the same. Following is a quick look at three important ABN facts.

If you discover that a patient's upcoming procedure is not payable by Medicare but the patient still wants you to perform the service, the ABN will let the patient know that he may be responsible for paying the noncovered portion.

ABNs help patients decide whether they want to proceed with a service even though they might have to pay for it. A signed ABN ensures that the physician will receive payment directly from the patient if Medicare refuses to pay. Without a valid ABN, you cannot hold a Medicare patient responsible for the denied charges, says Kara Hawes, CPC-A, coder with Advanced Professional Billing in Tulsa, Okla.

"The patient has to sign the ABN form at the time of service, otherwise the form is not valid," Hawes says. "When the claim is denied without an ABN, Medicare will not allow you to be reimbursed for the service or collect money from the patient."

ABNs help the patient understand his options. Once you have completed the ABN and discussed it with the patient, he can: 1) sign the ABN and assume financial responsibility for the procedure in question; 2) cancel the procedure; or 3) reschedule the procedure or service for a future date when he can afford it, or when Medicare may cover the procedure.

When you expect Medicare to deny all or part of a service, you should append the correct modifier to the service code so Medicare's explanation of benefits (EOB) will properly outline when the patient has to pay. Use the following descriptions to guide your modifier choice:

"The GA modifier (Waiver of liability statement on file) is used when the service provider believes the service is not covered and the office has a signed ABN on file," says Dena Rumisek, biller with Grand River Gastroenterology PC, in Grand Rapids, Mich. This might include tests ordered without a payable diagnosis code or those ordered more frequently than covered.

Modifier 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) applies when Medicare excludes the service and you're using the new ABN as you would have used the NEMB in the past.

Modifier GZ (Item or service expected to be denied as not reasonable and necessary) means that you didn't issue an ABN when you probably should have, and you cannot bill the patient when Medicare denies the service.

On occasion, an asymptomatic patient may request a colonoscopy that does not meet Medicare's screening requirements. In such cases, your best bet to collect payment is to bill the patient directly for the service.

For instance: A covered Medicare patient younger than 50 years of age with no apparent symptoms and low-risk factors may ask for a screening "just to be sure," or a high-risk beneficiary who has had an exam within 18 months may request an exam for similar reasons.

To ensure that the patient understands that he will be responsible for payment, you should request that he read and sign an ABN. You should present the patient with the ABN well in advance of the procedure and explain to the patient why Medicare will likely deny the service.

Remember: "An ABN tells the patient it's likely that Medicare won't cover the service, and therefore it will be the patient's responsibility to pay if the service is uncovered," says Cecile M. Katzoff, MGA, vice president for consulting services at the American Gastroenterological Association and the director of the AGA Center for GI Practice Management and Economics. "The patient can then determine whether or not he wants to have the procedure done, given the fact it's likely he will have to pay for it."

Medicare does not mandate that you use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless the doctor's office has a signed ABN. The ABN proves to Medicare that the patient understands that he might be responsible for the bill, Katzoff says.

Note: For more information on the new ABN form, visit http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp#TopOfPage.