Modifier Coding Alert

Question: How can I avoid writing off charges for services if I know Medicare will deny the service as not being medically necessary?

Wisconsin Subscriber

Answer: If you think Medicare will deny a claim due to lack of medical necessity, you should have the patient sign an advance beneficiary notice (ABN). Then, you can use modifier GA (Waiver of liability statement issued as required by payer policy, individual case) on the procedure or service code you submit. Use of this modifier says you expect your billing department to hold the patient financially responsible for the service if the payer denies the claim. It alerts your billing area to charge the patient for the service instead of writing the charge off. 

Example: Before your physician offers a patient telephone care using codes 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional …), the office should develop a process when the patient is first seen in the office. The process would include asking her if she might be interested in phone call evaluations in the future. If she thinks that might be a viable option, the paperwork process should then include her signing a proper ABN at that time. Then, when she calls in for that type of evaluation, have the receptionist remind her of her acceptance of the service through the ABN process. This way, rather than coming in for a visit, her services will be provided over the phone and she could be responsible for the fee should her insurance not cover that type of service. The receptionist notes the patient’s acknowledgement in their conversation, and the coder would then append the “GA” in field 24D of the CMS-1500 form with the appropriate time-based telephone code, such as 99442  (Telephone evaluation and management service by a physician or other qualified health care professional … 11-20 minutes of medical discussion). When the insurer denies the 99442-GA service as non-covered, the biller reviewing the EOB would then send the patient a bill.

According to CMS “You should only provide ABNs to beneficiaries enrolled in Original (Fee-For-Service) Medicare. ABNs allow beneficiaries to make informed decisions about whether to get services and accept financial responsibility for those services if Medicare does not pay. The ABN serves as proof the beneficiary knew prior to getting the service that Medicare might not pay. If you do not issue a valid ABN to the beneficiary when Medicare requires it, you cannot bill the beneficiary for the service and you may be financially liable if Medicare doesn’t pay.” Validity includes, but is not limited to, indicating why Medicare may not consider the service for payment and what the potential payment due by the patient could be.

“You may also use the ABN as an optional (voluntary) notice to alert beneficiaries of their financial liability prior to providing care that Medicare never covers. ABN issuance is not required to bill a beneficiary for an item or service that is not a Medicare benefit and never covered,” CMS continues.

Take note: Many non-Medicare payers also accept waivers of liability that allow you to bill the patient for a non-covered service. Check with your payer.