Gastroenterology Coding Alert

Question: Is there a modifier I can use to let Medicare know I have an ABN on file?


Washington Subscriber

Answer: Modifier GA (Waiver of liability statement on file) should let Medicare know you have an advance beneficiary notice (ABN) on file.

Example: A patient with gastroesophageal reflux disease (GERD) opts to have the Stretta procedure, and you know that not many Medicare carriers reimburse 43257 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease). For that reason, your practice makes sure to get an ABN on file.

The ABN instructs the patient that you suspect that  Medicare won't pay for the service, and the patient must choose whether he is willing to receive the service knowing he may have to pay. The ABN should include an estimate of the cost, and you should have the patient sign and date the document. You then report 43257 and append GA.

Tip: If you don't get a signed ABN, append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to let Medicare know you-re aware the payer is unlikely to cover the service but you don't have an ABN.

Also ensure that you don't obtain -blanket- ABN forms from all or most of your patients. You should only get ABNs when your practice has ample reason to believe that Medicare will deny the claim.