Radiology Coding Alert

Use it wisely: The OIG is watching $400-million-modifier GY.

Just in time for CMS' implementation of its revised Advance Beneficiary Notice of Noncoverage (ABN), the OIG has decided to target modifier GY use in its 2009 work plan. Take a few minutes to be sure you're up to speed on using ABNs and related modifiers.

You may use the new ABN already. But on March 1, the new ABN officially replaces the previous ABN-G (for physicians and therapists) and the ABN-L (for laboratories). It also incorporates the Notice of Exclusions from Medicare Benefits (NEMB), which is good news if you struggled to differentiate between ABNs and the NEMB. CMS expects the new combination form to "eliminate any widespread need for the NEMB in voluntary notification situations," according to the new ABN Form Instructions document.

Old way: In the past, ABNs were only for procedures that Medicare might not cover due to medical necessity (limited by local or national coverage determinations, frequency, etc.); the ABNs didn't apply to procedures or items that were statutorily excluded from Medicare benefits. That was when you used the NEMB as a back-up: for services beyond the stated limits (that didn't fall under an exception) because Medicare never covered them.

"Practices are not required to use an NEMB, but it's good business to notify and inform patients that they are receiving a service that's not covered by Medicare and the cost will fall to them," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Easy fix: Now CMS accepts the new ABN for either purpose, noting that "the revised version of the ABN may also be used to provide voluntary notification of financial liability."

Remember: ABNs help patients decide whether they want to proceed with a service even though they might have to pay for it, says Kara Hawes, CPC-A, with Advanced Professional Billing in Tulsa, Okla.

A signed ABN ensures that your practice will receive payment directly from the patient if Medicare refuses to pay. Without a valid ABN, you can collect for statutorily excluded services, but you can't hold the patient responsible for charges Medicare denies as not med-ically necessary.

You can find the new ABN form and filing instructions at www.cms.hhs.gov/BNI. Click on the link for "FFS ABN-G and ABN-L," then download the forms and instructions for "Revised ABN CMS-R-131."

When you expect Medicare to deny all or part of a service, you should append the correct modifier to the service code so Medicare's explanation of benefits (EOB) will properly outline when the patient has to pay. Use the following descriptions to guide your modifier choice.

Use Modifier GA (Waiver of liability statement on file) when you believe "the service is not covered, and the office has a signed ABN on file," says Dena Rumisek, a biller in Grand Rapids, Mich.

You might need modifier GA when you perform a CT for a condition which is not on the local carrier LCD (such as headache), says consultant Lori Hendrix, CPC, CPC-H, with Coding Strategies Inc. in Powder Springs, Ga.

Keep in mind: "The patient has to sign the ABN form prior to or at the time of service, otherwise the form is not valid," says Hawes. "When the claim is denied without an ABN, Medicare will not allow you to bill the patient for the service."

However, when the patient signs the ABN and you submit modifier GA with the claim, the patient EOB will state that the "Physician may bill the patient for the service," letting the patient know your physician is authorized to bill him.

Modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, it is not a contract benefit) applies when Medicare excludes the service, and you're using the new ABN as you would have used the NEMB in the past.

Screening exams for certain patients may require modifier GY. For example, you may perform an abdominal aortic aneurysm (AAA) screening for a patient-outside of the "Welcome to Medicare" timeframe, so Medicare won't cover the service, Hendrix says. The patient may-"ask the provider to submit a claim for such a service by checking option 1 on the ABN. The patient may choose this option because he or she needs a Medicare denial in order to obtain payment for the service from a secondary payer," Hendrix says.

Caution: The OIG intends to review the appropriateness of modifier GY use "on claims for services that are not covered by Medicare," the OIG 2009 Work Plan states.

You're not required to issue a notification for excluded procedures, and the OIG notes this means beneficiaries may "unknowingly acquire large medical bills that they are responsible for paying." In fact, Medicare denied over $400 million in modifier GY claims in 2006. We'll keep you posted on whether the OIG review results in a change to ABN requirements.

Modifier GZ (Item or service expected to be denied as not reasonable and necessary) means that you didn't issue an ABN, and you cannot bill the patient if Medicare denies the service. "This means that an ABN should have been provided and signed, but it was not," says Cobuzzi. "The practice realized this and is letting Medicare know that the ABN was not signed, and they will not balance bill the patient if and when the service is denied for medical necessity."