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 Never Covers Service

You don't need to ask the patient to sign an ABN when the ophthalmologist performs procedures or services that Medicare never covers (such as refractions or refractive surgery). The physician may still give the patient a notice of exclusion from Medicare benefits (or NEMB) to verify that he is responsible for the service's cost. Patients may even request that the physician submit a claim for never-covered 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. This modifier automatically prompts Medicare to generate a denial notice for the claim, which the patient may use to seek payment from secondary insurance.

Example: An ophthalmologist who has established a separate charge for 92015 (Determination of refractive state) performs a refraction on a patient. The patient needs a denial from Medicare so that his secondary insurance will cover the service. Report 92015-GY to Medicare. 

Another way: Modifier GY helps keep your records accurate and helps speed up Medicare's denial process, but it's not mandatory. If using the modifier complicates payment from the secondary insurer, don't use it, says Elizabeth Borgen, coding and billing specialist for the North Dakota Eye Clinic and Surgery Center in Grand Forks.

"The secondary wasn't understanding the Medicare denials with modifier GY, and I had a mess," she says. Her solution: submitting 92015 without modifiers to Medicare, waiting for their denial, and then submitting it to the secondary insurer.

Key: Modifier GY is only appropriate for services Medicare never covers. Check the status code for the procedure in the Physician Fee Schedule Database--if the code is "N," Medicare never covers that service. These codes are also specially marked in many CPT manuals.

Bonus resource: You can find a sample ABN and NEMB at the CMS Web site www.cms.hhs.gov/medicare/bni.