Ophthalmology and Optometry Coding Alert

Decide between GA and GY based on whether Medicare covers the service

If you don't want to get caught absorbing the cost of an uncovered service that a patient requests or the ophthalmologist recommends, you should reach for an advance beneficiary notice (ABN) and append modifier GA to the CPT code submitted to Medicare.

Properly used, the ABN/modifier combination allows you to collect payment directly from the patient. Alert CMS to ABN With GA The proper time to have the patient sign an ABN is prior to performing the service or procedure for which you normally expect to receive 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. You must provide an explanation on the ABN as to the type of service recommended and why you think  Medicare may deny coverage for it.

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 modifier GA, it will send an explanation of benefits 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 Medicare patient requests a glaucoma screening. Medicare covers glaucoma screenings for high-risk patients, but the ophthalmologist isn't sure the patient will meet Medicare's description of "high risk." Because you are unsure whether Medicare will cover the procedure, you ask the patient to sign an ABN. The ABN outlines the service the ophthalmologist will provide (glaucoma screening) and the reason Medicare may reject payment (patient may not be eligible). Submit a claim of G0117-GA (Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist; Waiver of liability statement on file). List Specific Service on ABN An advance beneficiary notice is a written notice to a Medicare beneficiary that Medicare may not cover a particular service or procedure. By signing the waiver, the patient acknowledges that he will pay for the procedure or service if Medicare does not.

The ABN must clearly identify the service or procedure the ophthalmologist plans to provide and state why Medicare may not provide coverage. The ABN affects only those services and procedures you've specifically listed.

You should not give an ABN to a beneficiary if you have no specific, identifiable reason to believe Medicare will not pay. In all cases, you should provide the patient with a completed and signed copy of the ABN for his records. Use GY if Medicare [...]