Ophthalmology and Optometry Coding Alert

Proper G-modifier use unlocks otherwise denied reimbursement When your office performs a service - even a noncovered procedure like cosmetic blepharoplasty or certain glaucoma screenings - you deserve payment for it. If you don't want to get caught absorbing the cost of services that a patient requests or the ophthalmologist recommends, and you know Medicare will not reimburse for a given service, you'd better use modifier -GA and reach for an advance beneficiary notice (ABN).

Properly used, the modifier/ABN combination allows you to collect payment for the ophthalmologist'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 the ophthalmologist performs the service or procedure that you don't think the patient's carrier will reimburse. 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.

Rule: After you've secured a signed ABN from a Medicare 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 may not inform the patient of his responsibility.

Real-World Example: A Medicare patient requests a glaucoma screening. Medicare covers glaucoma screenings for high-risk patients, but the doctor isn't sure the patient will meet Medicare's description of "high risk." You have the patient sign an ABN and submit a claim of G0117-GA (Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist; Waiver of liability statement on file). Medicare denies the claim and sends an EOB to the patient, explaining that he is not considered at high risk for glaucoma. Use Modifier -GY for Statutorily Noncovered Services An ABN is not necessary when the surgeon performs procedures or services that Medicare never covers (such as vision correction for refractive error). The doctor may still ask the patient to sign an ABN to verify that he is responsible for the service's cost. And, some patients want the physician to 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 ophthalmologist's services with modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) appended in addition to -GA. Medicare will generate a denial notice for the claim, which the patient may use to seek payment [...]