Urology Coding Alert

Bonus: The new ABN will eliminate NEMB confusionIn 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.Let the Modifiers Explain Your ABN SituationYou 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:• Modifier GA (Waiver of liability statement on file) applies when you need to notify Medicare that you have a signed ABN on file for a service that Medicare may not cover as medically necessary, says MaryJo McKenna, CPC, central business office manager for Northern Virginia Urology in Fairfax. This might include tests ordered without a payable diagnosis code or those ordered more frequently than covered.• Modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) applies when Medicare statutorily excludes the service and you're using the ABN as you would have used the NEMB in the past. "This allows the denial for the secondary payor to hopefully pick up," says Nancy L. Reading, RN, BS, CPC, CPC-I, CEO of CedarEdge Medical LLC in Salt Lake City, Utah.• Modifier GZ (Item or service expected to be denied as not reasonable and necessary) means that you didn't issue an ABN when you probably should have, and you cannot bill the patient when Medicare denies the service.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 [...]