General Surgery Coding Alert

Question: We have an ABN notice for a patient’s low-risk screening colonoscopy because the physician ordered the test five years after a normal test, meaning that it exceeds frequency limitations. What can we do to get paid for this test?

Georgia Subscriber

Answer: You’re in luck that you have an advance beneficiary notification (ABN), because without one, your surgeon wouldn’t get paid for the procedure. As you said, five years following a normal colonoscopy with no other symptoms and no high-risk for colon cancer is too soon for another screening procedure.

The answer to your problem is to use a modifier with the colonoscopy code. Let’s say your surgeon is billing Medicare G0123 (Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision), which would be an appropriate screening-test code.

You should append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) to the test code, because the payer policy requires an ABN for a test that exceeds the frequency limitation, and you do have one on file.

The other ABN modifiers would not be appropriate in this case. They are as follows:

• GX (Notice of liability issued, voluntary under payer policy): Use this modifier when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded, or is not a Medicare benefit. You might do this as a courtesy to the patient before billing them, even though Medicare doesn’t require an ABN in this case.
• 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): Use this modifier to report that Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. You may use this modifier in combination with modifier GX if you have an ABN on file.
• GZ (Item or service expected to be denied as not reasonable and necessary): Use this modifier when you expect Medicare to deny payment of the item or service due to a lack of medical necessity, and no ABN was issued. You cannot bill a patient for a claim that you file with modifier GZ.

Remember: You should use the latest ABN form approved by the Office of Management and Budget. The current form is for use from June 21, 2017 through March 2020.