Neurosurgery Coding Alert

Why 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 surgeon 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 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 in Atlanta.

After the patient has signed the ABN, 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.

Example: 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 surgeon will provide (epidural injection) and the reason Medicare may reject payment (excessive frequency).

The surgeon provides the injection, 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.

Use GY for Statutorily Noncovered Services

You don't need to ask the patient to sign an ABN when the surgeon performs procedures or services that Medicare never covers (such as intradiskal electrothermal therapy, 0062T, Percutaneous intradiskal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level).

The physician may still ask the patient to sign an ABN to verify that he is responsible for the service's cost, Fulkerson says. Or, more appropriately, the physician could ask the patient to sign a Notice of Exclusions from Medicare Benefits form (which simply states that the service is not a covered Medicare benefit). 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 code 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.

Example: The surgeon suggests that the patient receive an artificial disk to treat cervical spinal degeneration. But Medicare considers placement of artificial disks investigational and will not pay for the procedures. The patient agrees to undergo the procedure, and you ask him to sign a Notice of Exclusions from Medicare Benefits.

Following surgery, you report 0090T (Total disk arthroplasty [artificial disk], anterior approach, including diskectomy to prepare interspace [other than for decompression]; single interspace, cervical) for the artificial disk, and append modifier GY to demonstrate that you are aware the service is noncovered.

Bonus resource: You can find a sample ABN/Notice of Exclusions from Medicare Benefits at the CMS Web site www.cms.hhs.gov/medicare/bni/20007_English.pdf.

No ABN? Turn to 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,- she says.