Orthopedic Coding Alert

Question: A Medicare patient requested an ankle x-ray quite insistently, but it appears that he doesn’t meet the medical necessity criteria for the service. How should we proceed with this request?

Wisconsin Subscriber

Answer: This sounds like an instance where it would behoove your practice to have a signed advance beneficiary notice (ABN) on file before providing the x-ray. If you have a signed ABN, you can bill the patient for whatever portion of the x-ray Medicare won’t pay for.

The skinny: Whenever your practice provides a service that Medicare might not cover, or cover completely, the ABN notifies the patient of that fact. Having a signed ABN will allow you to bill the patient for the service. Without the ABN, you have no billing recourse.

You should do everything possible to get a signed ABN when:

• You believe Medicare may not pay for an item or service;
• Medicare usually covers the item or service, but might not for some reason; or
• Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

If at all possible, Medicare wants providers to issue an ABN directly to the patient. When this is not possible, you may issue an ABN via:

• Direct telephone,
• E-mail,
• Traditional mail or
• Secure fax machine.

If you can’t document that the patient received the ABN in person, note it in the patient’s record. Then, the beneficiary must send a signed ABN back to your practice — if at all possible.

Modifier alert: You’ll also want to append one of the following modifiers to any claim that contains an ABN, depending on encounter specifics:

• GA:  (Waiver of liability statement issued as required by payer policy, individual case). Use this modifier to report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN, but you must have it available on request.
• GX: (Notice of liability issued, voluntary under payer policy). Use this modifier to report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier in combination with modifier GY.
• 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 report that Medicare statutorily excludes the item or service or the item or service does not meet the definition of any Medicare benefit. You may use this modifier in combination with modifier GX.
• GZ: (Item or service expected to be denied as not reasonable and necessary). Use this modifier to report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued.