Neurology & Pain Management Coding Alert

Proper modifiers and a signed ABN can make the difference

If you don't want to get caught absorbing the cost of an uncovered service that a patient requests or the neurologist recommends, you should reach for modifier -GA and an advance beneficiary notice (ABN). Properly used, the modifier/ABN combination allows you to collect payment directly from the patient.

Modifier -GA Alerts Medicare of a Signed ABN

The proper time to have the patient sign an ABN is before providing the service or procedure for which you want to recoup payment. 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, says Jeff Fulkerson, BA, CPC, CMC, certified coder at The Emory Clinic.

After you've secured a signed ABN from the patient, you must inform Medicare by appending modifier -GA (Waiver of liability statement on file) to the CPT code describing the (suspected) noncovered service or procedure. When Medicare sees the -GA modifier, it will send an explanation of benefits (EOB) to the patient confirming that he is responsible for payment. If you don't append the modifier, Medicare will not inform the patient of his responsibility.

Real-World Example #1: A patient with chronic lower-back pain requests an epidural injection (62311, Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

This patient has already received six such injections in the past 12 months -- the maximum number his Medicare carrier will reimburse in a one-year period without extenuating circumstances. Because you are unsure if Medicare will cover the procedure, you ask the patient to sign an ABN. The ABN outlines the service the neurologist will provide (epidural injection) and the reason Medicare may reject payment (excessive frequency).

The neurologist screens the patient, and you report the service using 62311 with modifier -GA appended. In this case, because the patient has exceeded the frequency guidelines, Medicare denies the claim and sends the patient an EOB explaining that the service is not covered.

Use Modifier -GY for Statutorily Noncovered Tests

You don't need to ask the patient to sign an ABN when the neurologist performs procedures or services that Medicare never covers (such as intradiskal electrothermal therapy [IDET] or acupuncture). The physician may still ask the patient to sign an ABN to verify that he is responsible for the service's cost, Fulkerson says. 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 neurologist'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: The neurologist meets with an elderly patient previously diagnosed with carpal tunnel syndrome (354.0) by another neurologist, Dr. Smith. Dr. Smith recommended immediate surgical intervention to treat the condition, but the patient's daughter, unwilling to allow surgical intervention without a second opinion, has requested a confirmatory consult (99271-99275).

You know that Medicare does not cover confirmatory consultations and ask the patient to sign an ABN acknowledging this. You report the claim with the appropriate consult code (for example, 99274, Confirmatory consultation for a new or established patient ...) with modifier -GY appended.

No ABN? Use Modifier -GZ

If you should have had a patient sign an ABN but failed to do so, you should append modifier -GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the noncovered service the physician provided.

"You don't want to be in the position to use modifier -GZ, because it means that you probably won't get paid," 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."