Pain Management Coding Alert

Question: I am new to coding for Medicare beneficiaries, and I'm still trying to master all the ins and outs of advance beneficiary notice (ABN) coding. I have two questions:

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

What role do G modifiers play in ABN coding?

Oklahoma Subscriber

Answer: Advance beneficiary notices (ABNs) are forms that you'll get the Medicare patient to sign when the payer won't - or might not - pay for all or part of a procedure or service. If you obtain a signed ABN through the proper patient channels, it gives the practice the right to bill the patient for any portion of the procedure or service Medicare might not pay for.

Mandatory vs. voluntary: A mandatory ABN is for situations when a provider must issue an ABN, as directed by its Medicare Administrative Contractor (MAC). In those cases, you will consider the signed ABN mandatory in order to go forward with the service.

There are other instances where ABNs are voluntary - a provider can issue an ABN as a courtesy, but is not officially required to by Medicare. 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). In these cases, the beneficiary does not need to sign the form or check off any boxes as they would for a mandatory ABN.

Mandatory affects modifier choice: Depending on the service and the nature of the ABN, you will want to choose from one (or more) of four modifiers when issuing (or opting not to issue) an ABN:

• modifier GA (Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case);
• modifier GZ (Item or Service Expected to Be Denied as Not Reasonable and Necessary);
• modifier 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
• modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy).

For more information on proper ABN use, see: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ABN_Booklet_ICN006266.pdf.

---