Ophthalmology and Optometry Coding Alert

Question: We haven’t customarily used advance beneficiary notices (ABNs) in our practice unless we’re on the fence about whether a payer will reimburse a procedure, but our doctor wants us to start using them even if we know the insurer won’t pay. Can you advise on how to do this?

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Answer: An ABN, or Advance Beneficiary Notice, is a form that you should get a patient to sign when your practice provides a service that Medicare might not cover completely, or at all. You can bill the patient for the service if you have a signed ABN but you must also append the correct modifier to the service when the claim is submitted. Without the ABN and modifier appendage, you have no billing recourse if Medicare doesn’t pay for part or all of a patient’s service. 

You are also required to provide the patient with a copy of the ABN and the office should keep the original ABN on file. Be sure the language contained in the ABN is easily understood by the patient (don’t use CPT^® codes and diagnosis codes—instead, use a verbal description) and in terms the patient recognizes.  Be sure to estimate the cost of the services that will be rendered as well. The patient must select an option and sign the ABN. Often, these forms are incorrectly completed and are deemed invalid by Medicare.

Also: Experts also recommend giving patients ABNs even when you know that Medicare will deny the service. Medicare does not require an ABN if it explicitly excludes the service by statute, but many analysts think it’s a good idea. Examples of this would be refraction or cosmetic eye procedures.

In these situations, the payer expects you to append one of the following modifiers to the CPT^® code you are reporting for the service:

• GA (Waiver of liability statement issued as required by payer policy, individual case): Use this modifier to indicate you’ve issued a mandatory ABN for a service as required, and it is on file. 
• GX (Notice of liability issued, voluntary under payer policy): Use this modifier when you give a patient an ABN for a service that Medicare never covers. In certain situations, you can also use this modifier in combination with modifier GY (see below).
• 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): Use this modifier to when Medicare excludes the item or service; or the item or service does not meet the definition of any Medicare benefit. In certain situations, you can also use this modifier in combination with modifier GX.
• GZ (Item or service expected to be denied as not reasonable and necessary): Use this modifier when you think Medicare will deny payment due to lack of medical necessity, and you didn’t issue an ABN.

Keep in mind: Although Medicare is the one payer that requires ABNs in certain situations, it can be a good idea to use them with private payers as well so you can ensure that the patient will pay you for a service if it’s denied.