Urology Coding Alert

In March, CMS unveiled its new Advance Beneficiary Notice (ABN) which not only replaces both the previous ABN-G (for physicians) and ABN-L (for laboratories) but also incorporates the notice of exclusions from Medicare benefits (NEMB) form.

But getting the patient to sign an ABN isn't enough. If you don't know how to apply the proper modifier to your claims, you'll still end up with a denial and no payment for the urologist's services. Ensure you get paid every time with these coding tips.

You should append modifiers to explain ABN status to your carrier. When you expect Medicare to deny all or part of a service, you should attach the correct modifier to the service code so Medicare's explanation of benefits (EOB) will properly outline that the patient may be responsible for payment of the service in question. Use the following descriptions to guide your modifier choice:

Coding example: Because of personal concerns, a patient asks that a urologist perform a second screening prostate-specific antigen (PSA) determination, although he had one within the last year. Medicare will reimburse only one screening PSA (G0103) annually based on medical-necessity guidelines. Medicare most likely won't pay for this second study. You should have the patient sign an ABN to ensure that he understands that he will most likely be financially responsible for this second screening PSA. Submit G0103 (Prostate cancer screening; prostate specific antigen test [PSA]) with modifier GA appended when you have the patient sign an ABN.

"Most patients do not know if their PCP or internist had ordered a PSA in the current calendar year," McKenna says. "Unless there is medical necessity, such as elevated PSA (790.93) or the patient has prostate cancer (185), a second PSA test would not be covered." If the patient sees your urologist for another problem and needs to establish a PSA baseline or if the physician wants to check the patient's PSA because his last test was a year ago, McKenna recommends advising the patient, obtaining the ABN signature, and attaching modifier GA.

Although CMS changed the ABN form, many of the previous ABN "best practices" remain the same. Re-member these two additional important ABN facts to avoid providing services and procedures for which you cannot collect because you don't have a proper ABN.

Tip 1: The ABN is still one of your most important documents because Medicare requires an ABN when there is a chance of denial due to a lack of medical necessity. If you discover that Medicare won't pay for a patient's upcoming procedure and the patient still wants you to perform the service, the ABN lets the patient know that he may be responsible for paying the non-covered portion.

You shouldn't have the patient sign an ABN for a service "just because it is going to be denied for just any reason, but due to medical necessity," Reading says. "Some practices are of the mindset this must be signed for everything and that is not appropriate."

ABNs help patients decide whether they want to proceed with a service even though they might have to pay for it. A signed ABN ensures that the physician will receive payment directly from the patient if Medicare refuses to pay. Without a valid ABN, you cannot hold a Medicare patient responsible for the denied charges.

"I believe the ABN not only benefits the patient but also the practice," McKenna says. "When patients are informed ahead of a procedure or test of the potential for financial responsibility they feel they are involved in the decision making and are prepared for any denial."

Tip 2: You must explain the ABN to the patient. ABNs help the patient understand his options. You must have the patient sign prior to the physician providing the service and the ABN must cite why the payer might consider the service not medically necessary, Reading explains. Once you have discussed the ABN with the patient, he can: 1) sign the ABN and assume financial responsibility for the procedure noted on the ABN; 2) cancel the procedure; or 3) reschedule the procedure or service for a future date when he can afford it, or when Medicare may cover the procedure.

If you dread having to decide whether an ABN or an NEMB is appropriate for your physician's services, the new ABN form will ensure those worries go away.

CMS expects this new, combined 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, you used ABNs only for procedures that Medicare might not cover due to lack of medical necessity. If Medicare statutorily excluded the procedure from Medicare benefits, you turned to the NEMB. You were able to use NEMBs for services such as cosmetic surgery, which Medicare never covers. Keep in mind that Medicare didn't require that you use the NEMB, whereas it requires ABNs.

New way: Now CMS will accept the new ABN form for either purpose, noting in its ABN instructions that "the revised version of the ABN may also be used to provide voluntary notification of financial liability."

Don't worry: Although Medicare carriers began accepting the new ABN form as of March 3, CMS has implemented a six-month transition period. Therefore, you aren't required to submit the new form until Sept. 1.

Read more: For more on the new ABN form, visit http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp.