Urology Coding Alert

Your office doesn't have to pick up the tab for procedures Medicare won't cover

If your aren't appropriately using advance beneficiary notices (ABNs) for uncovered Medicare services, your office could be writing off thousands of dollars a year. Use this expert advice to ensure that doesn't happen.

What Makes an ABN So Important?

There are two main reasons you would want to obtain an ABN, says Stacie L. Buck, RHIA, LHRM, president and founder of Health Information Management Associates Inc. "The first is to increase your revenue, and the second is to reduce your risk or the compliance implications associated with ABNs," she says.

If your urologist recommends a treatment or procedure to a patient whom Medicare may not cover, you should request that the patient sign an ABN. The document will help the patient decide whether he wants to proceed with the service even though he may have to pay for it, and, once signed, the ABN also ensures that your office will receive payment directly from the patient if Medicare won't pay on it.

An advance beneficiary notice (ABN) is a written notice that informs the beneficiary that Medicare may not cover a particular service or procedure. By signing the waiver, the patient acknowledges that he will pay for the procedure or service if Medicare does not.

Example: Because of personal concerns, a patient asks that your urologist perform a second screening prostate-specific antigen (PSA) determination, although he had one within the last year. By statute, Medicare will only reimburse one screening PSA (G0103, Prostate cancer screening; prostate specific antigen test [PSA], total) annually. Medicare most likely won't pay on this second repeat study. You should have the patient sign an ABN to ensure that he understands that he will more than likely be financially responsible for this second screening PSA.

Let the Patient Know What He's Signing Up For

For your benefit and the patient's, the ABN should clearly identify the service/procedure the urologist plans to provide, the estimated charge for the service, and why Medicare may not provide coverage.

An ABN affects only those services/procedures you've specifically listed. You should therefore list all services your physician thinks Medicare may deny. You should also include your reasoning for why you think Medicare may deny the service, such as details from Medicare's coverage plan or examples of similar claims that have been denied.

Tip: You'll want one copy of each signed ABN for your records and one copy for the patient.

In some circumstances, you may not know for certain if Medicare will cover the service. When in doubt, protect yourself and request that the patient sign an ABN, says Jeff Fulkerson, BA, CPC, CMC, certified coder at The Emory Clinic in Atlanta. Your physician must obtain the ABN before performing the service.

You need to give the patient the opportunity to understand his options. He can: 1) be financially responsible for the exam by signing the ABN; 2) cancel the procedure; 3) reschedule the exam for a future date when he can afford it; or 4) refuse to sign the ABN and request that the urologist perform the procedure anyway. If the patient chooses not to sign the ABN and have the procedure done anyway, your physician should document the situation in detail in the patient's record, Fulkerson says. Moreover, the patient will still be financially responsible for the exam.

Give Medicare the Heads-Up With Modifier GA

When you obtain an ABN for a service your urologist performs that you don't expect Medicare to pay for, make sure you report the service with modifier GA (Waiver of liability statement on file). When Medicare sees modifier GA, it will send an explanation of benefits to the patient confirming that he is responsible for payment. If you don't append the modifier, Medicare will not inform the patient of his responsibility.

You don't need to ask the patient to sign an ABN when the surgeon performs procedures or services that Medicare never covers (such as plastic cosmetic surgery). In such cases, you should report the appropriate CPT code for the surgeon's services with modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) appended. Medicare will generate a denial notice for the claim, which the patient may use to seek payment from secondary insurance.

Don't overlook: If you believe that Medicare will reject your claim but you failed to have the patient sign an ABN, you should append modifier GZ (Item or service expected to be denied as not reasonable and necessary) to the CPT code describing the noncovered service the physician provided.

Bonus resource: Visit the CMS Web site at http://new.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf for a sample ABN.