Neurosurgery Coding Alert

Remember G modifiers on ABN claims.

If you’re having trouble keeping all of the rules for advance beneficiary notices (ABNs) straight, take a look at these FAQs to clear up some of the most common ABN issues:

Q: Do ABNs pertain to both procedural and evaluation and management (E/M) services?

A: Contrary to popular belief, ABNs are not exclusive to surgical procedures. “ABNs are more common for surgical, therapy and laboratory services, but there are instances where you will want to use an ABN for E/M encounters,” outlines Jennifer M. Connell, CPC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, Owner of E2E Health Solutions in Victoria, Texas.

For example, an initial preventative physical exam (IPPE) is a once-in-a-lifetime exam, so if a circumstance arises in which a patient requires a second IPPE, it warrants the issuance of an ABN. The same applies to annual wellness visits (AWV), which are only covered by Medicare once annually.

Additionally, physicians should issue an ABN to any Part B beneficiaries that receive a head-to-toe physical exam. “While annual physical exams are statutorily excluded and use of an ABN is voluntary, it is highly recommended that the provider issue an ABN for the annual physical exam in light of the misconception that an IPPE or AWV are the same as an annual physical exam,” Connell emphasizes.

Q: What is the difference between a mandatory and a voluntary ABN?

A: You’ve already learned about the instances when a provider must issue an ABN. In those cases, you will consider the ABN mandatory in order to go forward with the service. There are other instances where a provider can issue an ABN as a courtesy, but is not officially required to. This example of a voluntary ABN can be given to a patient for an item or service that Medicare never covers (i.e. fails to meet the definition of a Medicare benefit or service). In these cases, the beneficiary does not need to sign the form or check off any boxes as they would for a mandatory ABN.

Q: How should you bill uncovered services to Medicare?

A: Depending on the service and the nature of the ABN, you will want to choose from one of four modifiers (GA, GX, GY, GZ) when issuing (or opting not to issue) an ABN.

In cases where the provider issues a mandatory ABN, the claim should be sent out with modifier GA (Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case). The provider does not need to submit a copy of the ABN along with the claim, but should keep it on file in case Medicare requests any documentation.

You will apply modifier GZ (Item or Service Expected to Be Denied as Not Reasonable and Necessary) in the scenario in which a provider believes a service will be denied for lack of medical necessity, but does not opt to issue a voluntary ABN to the beneficiary.

In the case where a voluntary ABN is completed and the patient decides that they would like the claim submitted to Medicare for a coverage decision, you will want to apply modifiers GY (Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit or, for non-medicare insurers, is not a contract benefit) and GX (Notice of Liability Issued, Voluntary Under Payer Policy). You will use modifier GY to explain that Medicare statutorily excludes the item or service (or it does not meet the definition of a Medicare benefit). In addition, you will use modifier GX in any case where a provider issues a voluntary ABN for a service that Medicare does not cover.

Keep in mind: You will want to submit these claims and their respective modifiers in box 24D of the CMS 1500 claim form.