Practice Management Alert

At least one aspect of dealing with Advance Beneficiary Notice of Non-Coverage (ABN) forms is about to get a little simpler, thanks to two modifiers. CMS is now giving you two HCPCS level 2 modifiers to distinguish between voluntary and required uses of liability codes, according to release CR6563.

Background: When your physician provides a service that Medicare does not cover, your practice must provide an ABN to the patient. The patient should then examine and complete the form before your providers administer that service or procedure.

When you have a patient sign an ABN, you also need to append the appropriate modifiers on your claim. ABN modifiers tell the Medicare carrier that you have an ABN on file for services that won't be covered.

Luckily, modifiers GA (Waiver of liability on file) and GX (Notice of liability issued, voluntary under payer policy) should add more tools to your belt that will help you fend off denials.

Good practice: "It is in the provider's best interest to discover which procedures need ABNs in their offices, and flag accounts prior to the patient coming in," says Melinda Brown, CMBS, insurance biller with H. Matt Smith, MD, in Kennewick, Wash.

CMS redefined modifier GA to be a "waiver of liability statement." You should only use modifier GA "to report when a required ABN was issued for a service, and [GA] should not be reported in association with any other liability-related modifier and should continue to be submitted with covered charges," CMS says. Simply put, "the GA indicates that you have a signed ABN on file," Brown explains.

Unfortunately, using GA does not mean you'll get automatic reimbursement. According to the CMS guidelines, a GA modifier indicates the possibility that a service may be denied for medical necessity only, and that the physician may bill the patient after the claim is denied.

Example: A patient presents for lesion destruction (freezing) of seborrheic keratosis(es). In this case, you would bill 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratoses; first lesion) and 17003 (second through 14 lesions, each) times three units of service, for four total lesions with a diagnosis code of 702.19 (Other seborrheic keratosis). You'll need to obtain an ABN from the patient and then use modifier GA since Medicare may deny 17000 with any diagnosis except 702.0 (actinic keratosis), for medical necessity, says Brown.

When your practice issues a voluntary ABN for a particular service, you'll instead turn to modifier GX. CMS defines modifier GX as "notice of liability issued, voluntary under payer policy." You will use modifier GX when you need a denial remittance advice to submit for secondary insurance, when Medicare does not pay as primary, but the secondary insurance does pay with a denial explanation of benefits (EOB).

Old way: Before CMS revised the ABN last year, you would have used a Notice of Exclusion of Medicare Benefits (NEMB) form for these cases. CMS eliminated the NEMB, however, so modifier GX helps you tell the payer you have a voluntary ABN on file. You might also use the ABN for a never covered service if a patient does not believe the service is not covered and insists that you submit the claim to Medicare.

You would have the patient sign the ABN and submit the service to Medicare with a GX modifier so that the patient receives the denial remittance advice.

Watch for: If you append GX on the same line as many liability-related modifiers, including EY (No doctor's order on file), GA, GL (Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN), and others, Medicare will likely deny your claim.

Example: A patient needs a hearing aid, which Medicare never covers, but the patient has secondary insurance that will pay. The patient signs an ABN. You should submit the claim to Medicare with a GX modifier.

Your practice may then submit to the secondary insurance, which will pay for a part of the hearing aid based on the denial from Medicare.