General Surgery Coding Alert

Signature means you can bill beneficiary.

Master the appropriate use of advance beneficiary notifications (ABNs), and you can safeguard your general surgeons’ pay for services your insurance contractors won’t cover.

Medicare isn’t the only payer requiring ABNs these days, so knowing when and how to obtain patient-payment responsibility agreements is critical to your surgery practice’s bottom line.

Get in line with all of your payers by getting in the habit of issuing ABNs when necessary, so you don’t end up giving your providers’ services away for free.

Arrange an ABN When Medicare Might Not Pay

You should obtain a signed ABN for Medicare patients in the following situations, says Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida:

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

ABN alert: If your patient did not meet medical necessity criteria for any reason, you should get a signed ABN before performing the procedure or service. You’ll also need to attach modifier GA (Waiver of liability statement issued as required by payer policy, individual case). “Use this modifier when you issue a mandatory ABN for a service as required, and it is on file,” Verno explains. You don’t need to submit the ABN on “GA-modifier” claims, but you should have it available upon request, he adds.

Money matters: Your surgeons could lose deserved cash if it doesn’t have a signed ABN on file. If Medicare denies your claim and you don’t have a signed ABN, you can’t bill the patient, and your practice is on the hook for the procedure or service cost.

Get ABN Regardless Of Medicare Statutes

Speaking strictly from a coding perspective, if Medicare explicitly excludes the service by statute, it is not necessary to get an ABN, Verno confirms. But experts recommend getting an ABN in these situations, too, because it engenders patient good will. In these cases, you should bill the service with modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit…) to indicate that you don’t expect Medicare to pay, but want them to generate an explanation of benefits for the patient.

Do this: When the situation does not explicitly call for an ABN for Medicare compliance, you should move forward with the ABN to present the costs to the patient. Financial care of the patient goes hand-in-hand with their physical and emotional well-being. Worrying about paying an unexpected bill can impact a patient in some pretty negative ways.

Strive To Get ABNs Signed By Patient

If at all possible, you should issue an ABN directly to the patient, Verno says.

Here’s why: If you don’t have a face-to-face meeting about the ABN, “it is difficult to ensure patient comprehension of the document, and that all of the beneficiary’s related questions are answered timely, accurately, and completely to the best of the notifier’s ability,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at University of Pennsylvania Hospital.

However, when you can’t issue an ABN directly, you may use one of the following means:

• Direct telephone
• E-mail
• Traditional mail
• Secure fax machine.

For Medicare to consider an ABN issuance compliant, the beneficiary should acknowledge that you contacted her about the potential costs. Further, you must follow telephone contacts from the patient immediately by a hand-delivered, mailed, e-mailed, or faxed ABN, Verno says. Then, the beneficiary must send a signed ABN back to your practice.

Cover your bases: In case the patient does not sign and return the ABN before the procedure, Verno recommends you “keep a copy of the unsigned ABN on file. If the beneficiary fails to return a signed copy, document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the ABN,” he explains.

Without a signed ABN, you should bill the service with modifier GZ (Item or service expected to be denied as not reasonable and necessary). Reporting this modifier means you can’t bill the patient if the payer denies the service.

For more information on ABNs and related Medicare policy, please visit the Centers for Medicare & Medicaid Services’ web site at URL www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.