Otolaryngology Coding Alert

Enhance your understanding of the ABN process by utilizing these FAQs.

Putting a system in place for issuance of advance beneficiary notices (ABNs) is integral for any otolaryngology practice. But to fully grasp the fundamentals behind the ABN process, you've got to understand a few key points.

Here's a list of some of the most common ABN-related questions to help clear up any remaining confusion you might have from the previous issue of Otolaryngology Coding Alert (v19n9).

Q: Do ABNs pertain to both procedural and evaluation and management (E/M) services?

A: Contrary to popular belief, ABNs are not exclusive to surgical procedures. "ABNs are more common for surgical, therapy, and laboratory services, but there are instances where you will want to use an ABN for E/M encounters," outlines Jennifer M. Connell, CPC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, owner of E2E Health Solutions in Victoria, Texas.

For example, initial preventative physical exam (IPPE) is a once-in-a-lifetime exam, so if a circumstance arises in which a patient requires a second IPPE, it warrants the issue of an ABN.

The same applies to annual wellness visits (AWV), which Medicare only covers once annually. Additionally, physicians should issue an ABN to any Part B beneficiaries that receive a head-to-toe physical exam.

"While annual physical exams are statutorily excluded and use of an ABN is voluntary, it is highly recommended that the provider issue an ABN for the annual physical exam in light of the misconception that an IPPE or AWV are the same as an annual physical exam," Connell emphasizes. By issuing an ABN in these circumstances, the provider is giving the patient additional information and transparent pricing for the annual preventative exam.

Q: What is the difference between a mandatory and a voluntary ABN?

A: You've already learned about the instances when a provider must issue an ABN. In those cases, you will consider the ABN mandatory in order to go forward with the service. There are other instances where a provider can issue an ABN as a courtesy, but are not officially required to. This example of a voluntary ABN can be given to a patient for an item or service that Medicare never covers (i.e. fails to meet the definition of a Medicare benefit or service) such as hearing aids, cosmetic procedures, tonsil pillars, etc. In these cases, the beneficiary does not need to sign the form or check off any boxes, as they would for a mandatory ABN.

"One of the reasons to submit a claim that the practice and the patient knows will not be covered by Medicare is because the patient's secondary insurance covers the item or service," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, New Jersey. "In this case the secondary insurance requires a denial of the service or item in order to pay. This is commonly seen for hearing aid evaluations and services," Cobuzzi explains.

An example of a situation where you might want to use a voluntary ABN for a regularly covered service that may be denied for medical necessity is for a patient that frequently comes in for removal of impacted cerumen. Medicare has frequency limits on how often it will pay for this service, and your Medicare carrier will issue denials as not medically necessary if it feels that the physician is performing the cerumen removal too frequently. If you have the "frequent flyer" cerumen removal patient sign an ABN each time the patient presents for the service, you will be able to confidently bill the patient after Medicare inevitably denies the claim.

Q: How should you bill uncovered services to Medicare?

A: Depending on the service and the nature of the ABN, you will want to choose from one of four modifiers (GA, GX, GY, GZ) when issuing (or opting not to issue) an ABN.

In cases where the provider issues a mandatory ABN, the claim should be sent out with modifier GA (Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case). The provider does not need to submit a copy of the ABN along with the claim, but should keep it on file in case Medicare requests any documentation. The GA modifier is important because, should the service be denied, the patient remittance advice will state: "the doctor may bill you for this service." If the patient does not sign an ABN and the GA is left off the claim in addition to the service being denied, the remittance will indicate that the doctor may not bill the patient for the service.

You will apply modifier GZ (Item or Service Expected to Be Denied as Not Reasonable and Necessary) in the scenario in which the provider believes the payer will deny a service for lack of medical necessity, but does not opt (or forgets) to issue a voluntary ABN to the beneficiary.

In the case where a you have a completed voluntary ABN and the patient decides that they would like you to submit the claim to Medicare for a coverage decision, you will want to apply modifiers 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) and GX (Notice of Liability Issued, Voluntary Under Payer Policy). You will use modifier GY to explain that Medicare statutorily excludes the item or service (or it does not meet the definition of a Medicare benefit) and that you are not expecting payment despite the fact that you are submitting the claim for this line item. In addition, you will use modifier GX in any case where a provider issues a voluntary ABN for a service that Medicare does not cover.

"The GY and GX modifiers are be used for hearing aid evaluations and purchases where secondary insurance pays for the hearing aids," details Cobuzzi. "These secondary insurance companies require a denial from Medicare before they will pay for the hearing aids. Submitting the claims to Medicare with the GY and GX modifiers will provide the denial remittances needed for the secondary insurances to pay for hearing aids," Cobuzzi reiterates.

Keep in mind: You will want to submit these claims and their respective modifiers in box 24D of the CMS 1500 claim form.