Pathology/Lab Coding Alert

Missing signatures could mean a dip in your bottom line When an insurer won't cover a patient's lab test, you-ll have to eat the cost -- unless you have a signed advance beneficiary notice (ABN). That's why you need to know when and how to use these forms. Understand Basic ABN Need You should use an ABN when the patient's insurer won't cover a test because you cannot prove medical necessity, says Lena Robins, JD, senior counsel at Foley and Lardner LLP. For instance, when a Medicare carrier subjects a lab test to frequency limits, you will need a signed ABN if the physician orders the test at a shorter interval, Robins says.

Example: Medicare allows a patient to have only one screening prostate specific antigen (PSA) test per year (G0103, Prostate cancer screening; prostate specific antigen [PSA] test, total). Solution: If a patient says that he's had a prostate cancer screening within the past year, have him sign an ABN before you perform the test.

Some computer software will alert you if you need an ABN when you enter certain CPT and diagnosis code combinations. Computer systems such as Hospital Management System (HMS), Meditech and Cerner won't let you order a test without additional information, such as entering a diagnosis code, says Michelle Lloyd, laboratory director for Cass Medical Center in Harrisonville, Mo. These systems also print out ABNs for you to have the patient sign, she adds.

For example, if the physician orders a lipid test such as 82465 (Cholesterol, serum or whole blood, total) without a payable diagnosis code, the computer system will recognize the discrepancy and print out an ABN, Lloyd says. If you don't have this software available in your lab, you can download ABNs from the CMS Web site at www.cms.hhs.gov/cmsforms/downloads/cmsr-131-l.pdf. Differentiate Between Payers ABN rules are not the same for every payer -- Medicare has different guidelines than private insurers.

Medicare: When you don't expect Medicare to cover a test, you should use modifiers to indicate the ABN status as follows:

- GA (Waiver of liability statement on file). Append this modifier to the CPT code when you-ve secured a signed ABN because you know that Medicare probably won't cover a test based on medical necessity or frequency constraints.

- GZ (Item or service expected to be denied as not reasonable and necessary). Use this modifier when you expect Medicare to deny a claim but you do not have a signed ABN on file. Although it won't help you get paid, you reduce the risk of fraud allegations for filing claims that are not medically necessary.

- GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit). Medicare doesn't require a signed [...]