Pathology/Lab Coding Alert

Don't forget to add -GA

You can't exceed Medicare's frequency limitations for diabetes or cardio-vascular screening tests. Otherwise, your lab may be financially liable for the cost of the tests. That's why you need to know Medicare's final coverage rule - and how to use Advance Beneficiary Notice (ABN) and modifier -GA to protect your payment.

Medicare Limits Test Regularity

For diabetes screening, Medicare allows one screening test a year for patients without "pre-diabetes," or two screening tests per 12 month period for patients with the condition. CMS defines pre-diabetes as a previous fasting glucose of 100-125 mg/dL, or a two-hour post-glucose challenge of 140-199 mg/dL. When you see one of the covered glucose tests (82947, 82950, or 82951) ordered with diagnosis V77.1 (Special screening for diabetes mellitus), you'll need to be on the lookout for the last time the patient had the test. 

The frequency limitation for heart-disease screening is once every five years. Medicare covers three different tests once during that period: total cholesterol (82465), HDL cholesterol (83718) and triglycerides (84478). If the physician orders the three tests as a panel, you can only report the lipid panel (80061) once during five years. But don't report both the panel and the separate tests during the five years - CMS clarifies that "our intention is to cover ... total cholesterol, a triglyceride test, and an HDL cholesterol once every five years," regardless of whether the lab performs the tests separately or together.

Get Routine ABNs for Screening

Because you may not know when the patient last had one of these screening tests, the lab should obtain a signed ABN for the tests if the ordering physician has not already done so. You can issue routine ABNs when Medicare has imposed frequency limitations on services. CMS states, "The provider may routinely give ABNs to beneficiaries ... [which] must include the frequency limitation as the reason for which Medicare will deny coverage." You can get a copy of Medicare's laboratory ABN form on the Internet at http://cms.hhs.gov/medicare/bni/CMSR131L_June2002.pdf.

Protect yourself: After you've secured a signed ABN from the patient, you must inform Medicare that you have this information. "You tell Medicare that you have the ABN by appending modifier -GA (Waiver of liability statement on file) to the appropriate CPT code," says Mary Jo Bonifas, MT (ASCP), manager of laboratory services at United Clinical Laboratories in Dubuque, Iowa.

If Medicare denies the service because the patient exceeded the frequency limitation, the Medicare carrier will send an explanation of benefits (EOB) to the patient confirming that he is responsible for payment. If you fail to append modifier -GA, Medicare will not inform the patient of his responsibility to pay.