Otolaryngology Coding Alert

Tell patients up front about possible financial responsibility

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

Properly used, the ABN/modifier combination allows you to collect payment directly from the patient.

Modifier GA Alerts Medicare of ABN

The proper time to have the patient sign an ABN is before providing the service or procedure for which you want to recoup 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.

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 (EOB) 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 patient with laryngeal spasm (478.75) requests a Botox injection to combat his symptoms (for instance, 64999, Unlisted procedure, nervous system).

Get more info: See -Bill Botox Injections in Several Steps- later in this issue for further explanation on reporting Botox injections to the larynx.

This patient has already received two such injections in the past three months. Many insurers (including Medicare) limit the frequency of Botox treatments and will not pay for additional injections during a given time period without evidence of extenuating circumstances.

Because you are unsure whether Medicare will cover the procedure, you ask the patient to sign an ABN. The ABN outlines the service the surgeon will provide (laryngoscopy with Botox injection) and the reason Medicare may reject payment (excessive frequency). You would report 64999 with modifier GA appended.

The ABCs of ABNs

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/procedure the surgeon plans to provide and state why Medicare may not provide coverage. The ABN affects only those services/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.

Helpful hint: To obtain a standardized, sample ABN, visit the CMS Web site www.cms.gov and use the -search- function to locate form -CMS-R-131-G.-

Use GY for Statutorily Noncovered Services

You don't need to ask the patient to sign an ABN when the surgeon performs procedures or services that Medicare never covers (such as cosmetic rhinoplasty). The physician may still ask the patient to sign 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 noncovered services in hopes of receiving coverage from a secondary insurer.

In such cases, you should report the appropriate CPT code for the surgeon's services with modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) appended. Medicare will generate a denial notice for the claim, which the patient may use to seek payment from secondary insurance.

Example: The patient requests a hearing aid (for example, V5244, Hearing aid, digitally programmable analog, monaural, CIC). Medicare does not pay for hearing aids, but the patient's secondary insurer does provide coverage. The ENT has the surgeon sign an NEMB and appends modifier GY to V5244 to demonstrate he is aware the service is not covered by Medicare.

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

No ABN? Turn to GZ

If you should have had a patient sign an ABN but failed to do so, you should append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the noncovered service the physician provided.

-You don't want to be in the position to use modifier GZ because it means that you probably won't get paid,- says Joyce Ludwick, compliance consultant with Park City Solutions Group in Ann Arbor, Mich. -However, by notifying Medicare using modifier GZ, you reduce the risk of allegations of fraud or abuse when filing claims that are not medically necessary.-

Plan ahead: Don't allow yourself to resort to modifier GZ. Have a policy in place to collect ABNs (and NEMBs) when required.