Ob-Gyn Coding Alert

Heads up: A 6-month transition doesn't mean you should wait

CMS has unveiled its new advance beneficiary notice (ABN), and even though the hard deadline is several months away, you should take steps now to put it into practice.
Good news: The new ABN not only replaces the previous ABN-G (for physicians) but also incorporates the notice of exclusions from Medicare benefits (NEMB) form. 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.
The NEMB's previous purpose: In case you didn't know exactly when you were supposed to use the ABN rather than the NEMB, keep in mind that in the past, ABNs were only for procedures that Medicare might not cover but didn't apply to procedures that were statutorily excluded from Medicare benefits. That was where the NEMB came in " you were able to use it for services such as cosmetic surgery or the normal preventive annual well-woman examination bill using the preventive medicine codes (99381-99397), which Medicare never covered.
 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.
Although the ABN form has changed, many of the previous ABN -best practices- remain the same. Following is a quick look at three important ABN facts.

All Hail the Importance of the ABN

If a patient's upcoming procedure is not payable by Medicare but the patient still wants you to perform the service, the ABN will let the patient know that he may be responsible for paying the noncovered portion.
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, says Kara Hawes, CPC-A, coder with Advanced Professional Billing in Tulsa, Okla.
 -The patient has to sign the ABN form at the time of service, otherwise the form is not valid,- Hawes says. -When the claim is denied without an ABN, Medicare will not allow you to be reimbursed for the service or collect money from the patient.-

Clarify the ABN to the Patient

ABNs help the patient understand her options. Once you have completed the ABN and discussed it with the patient, she can 1) sign the ABN and assume financial responsibility for the procedure in question, 2) cancel the procedure, or 3) reschedule the procedure or service for a future date when she can afford it, or when Medicare may cover the procedure.
In other words: With the information provided on an ABN, the patient can make a more informed decision on whether she wants to have the procedure performed, given that it's likely she may have to pay for it. This educates her about what is and what is not covered in advance, says Bella Bailey, CCS-P, ASC-OB, coder for the Womankind Health and Wellness Center in Columbus, Ohio.

Explain ABN Status With a Modifier

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 the service provider believes payers don't cover the service and the office has a signed ABN on file. This might include tests or procedures 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 excludes the service and you-re using the new ABN as you would have used the NEMB in the past.
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.

Apply These Principles to Ob-Gyn Examples

Example 1: A low-risk Medicare patient presents to your office for a Pap smear as well as a pelvic and breast exam. You should report HCPCS codes Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). You should report V72.31 (Routine gynecological exam) for the diagnosis.
Here's the rub: Medicare will pay for one Pap test every two years for low-risk patients, and this patient wants to have a yearly checkup. To avoid getting stuck with the Medicare bill, you should inform the patient that she is responsible for this service fee. That's where an ABN comes in, experts say. In this case, you add modifier GA to both G0101 and Q0091. If Medicare does not cover the Pap smear or pelvic/breast exam, using modifier GA will allow you to collect from the patient.
In general, you should obtain an ABN each time a diagnostic or therapeutic procedure or test may not match up with the proper diagnosis code. If the patient has a diagnosis not listed on your local medical review policy (LMRP) for the procedure, but the ob-gyn still thinks the patient should have the procedure performed, you should get the patient to sign an ABN pre-procedure. 
Example 2: An ob-gyn performs a diagnostic Pap smear (Q0091) with a diagnosis of history of breast cancer (V10.3). In this case, the carrier may not reimburse this combination of procedure and diagnosis codes. Best bet: Have the patient sign an ABN.
Also, obtain an ABN when a patient comes in for a screening procedure but the office is unsure whether the procedure will violate Medicare's frequency rules. Remember: You don't need an ABN if Medicare never covers the service, such as a preventive medicine procedure (99381-99397). 
Example 3: Medicare mandates that 365 days must pass before it will cover a Medicare patient's next mammogram, Bailey says. Therefore if the ob-gyn sees reason for another screening mammogram before Medicare allows you to report the procedure again, get an ABN on file.
Note: For more information on the new ABN form, visit www.cms.hhs.gov/BNI/02_ABNGABNL.asp