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 secondary insurer.

In such cases, you should report the appropriate CPT for the surgeon's services with modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) appended. Medicare will generate a denial notice for the claim, which the patient may use to seek payment from secondary insurance.

Real-World Example #2: In a variation of the above example, a 45-year-old disabled male with high risk of colon cancer requests a screening. You know Medicare does not cover this service. You ask the patient to sign an ABN and collect payment up-front. You submit a claim of G0105-GY.

No ABN? Use Modifier -GZ

In those cases when you should have had a patient sign an ABN but did not, you should turn to modifier -GZ (Item or service expected to be denied as not reasonable and necessary).

"You don't want to be in the position to use modifier -GZ, because it means that you probably won't get paid for the service," says Joyce Ludwick, compliance consultant with Park City Solutions Group in Ann Arbor, Mich. "However, by notifying Medicare using modifier -GZ, you reduce the risk of allegations of fraud or abuse when filing claims that are not medically necessary."