General Surgery Coding Alert

Proper modifiers and a signed ABN allow you to collect payment

If you don't want to get caught absorbing the cost of services that a patient requests or the surgeon recommends, but you know Medicare will not reimburse, it's time to employ modifier -GA and reach for an advance beneficiary notice (ABN). Properly used, the modifier/ABN combination allows you to collect payment for the surgeon's effort directly from the patient. Attach Modifier -GA to Alert Medicare of an ABN The proper time to have the patient sign an ABN is before providing the service or procedure that you want to recoup payment for. In some circumstances, you may not know for certain if Medicare will cover the service. When in doubt, protect yourself and request that the patient sign an ABN.

After you've secured a signed ABN from the patient, you must inform Medicare that you have this information on the CMS-1500 form by appending modifier -GA (Waiver of liability statement on file) to the appropriate CPT code. When Medicare sees the -GA modifier and does deny payment for the service, it will send an explanation of benefits (EOB) to the patient confirming that he is responsible for payment. If you fail to append the modifier, Medicare will not inform the patient of his responsibility.

Real-World Example #1: A recently established 55-year-old male patient requests a screening colonoscopy. The patient is at high-risk for colon cancer and has had screenings in the past, although he does not recall when the last screening occurred and his previous Medical records are not available. Because Medicare will cover screenings only once every two years, and you are unsure of the date of the last screening, you ask the patient to sign an ABN. The ABN outlines the service the surgeon will provide (screening colonoscopy) and the possible reason Medicare will reject payment (excessive frequency).

The surgeon screens the patient, and you report the service using G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) with modifier -GA appended. In this case, the patient has exceeded frequency guidelines and Medicare denies the claim, sending the patient an EOB explaining that the service is not covered. You collect payment from the patient for the service at the time of his next visit. Use Modifier -GY for Statutorily Noncovered Tests An ABN is not necessary when the surgeon performs procedures or services that Medicare never covers (such as colorectal screenings for patients under 50 years of age). The surgeon may still ask the patient to sign an ABN to verify that he is responsible for the service's cost. And, some patients request that the physician submit a claim for noncovered services in hopes of receiving coverage from a [...]