Oncology & Hematology Coding Alert

Remember these 4 tips and stay on track for success.

Although the ABN form has changed and old forms will no longer be viable after March 1, many of the previous ABN "best practices" remain the same. Here's a quick look at four important facts to keep in mind when using ABNs.

If you discover that a patient's upcoming treatment might not be payable by Medicare due to medical necessity, but, based on clinical advice from the physician, 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. You-re required to provide an ABN specific to the service and get it signed by the patient in this case.

If, however, the service you-re providing is statutorily noncovered by CMS, you can choose to voluntarily provide the patient with the revised ABN, notifying her that this service is not covered by Medicare and that she is responsible for payment -- in other words, exactly how you would have handled using an NEMB form.

2. Keep Fresh Copies of the ABN Close By

"The patient has to sign the ABN form prior to or at the time of service; otherwise the form is not valid," says Kara Hawes, CPC-A, with Advanced Professional Billing in Tulsa, Okla. "When the claim is denied without an ABN, Medicare will not allow you to bill the patient for the service."

However, when the ABN is signed and the GA modifier (Waiver of liability statement on file) is submitted with the claim, the patient EOB (explanation of benefits) will state that the "Physician may bill the patient for the service," letting the patient know your physician is authorized to bill her.

ABNs help the patient understand his options. Once you have completed the ABN and discussed it with the patient, he can: 1) sign the ABN and assume financial responsibility for the service in question; 2) ask your physician why he is recommending a service that Medicare might deny; 3) cancel the service; 4) reschedule the service for a future date when he can afford it, or when Medicare may cover the procedure; or 5) decide to have a different, covered service performed instead.

4. Know Your Billing Modifiers

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:

- Modifier GA "is used when the service provider believes the service is not covered, and the office has a signed ABN on file," says Dena Rumisek, a biller in Grand Rapids, Mich. You might need modifier GA when the patient will be paying for a chemotherapy drug that is not paid by Medicare for the patient's diagnosis.

- 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. Use modifier GY when you know Medicare does not cover the service and you need a denial EOB before submitting to a secondary insurance carrier. You might also use modifier GY for submission to a drug replacement program.

- Modifier GZ (Item or service expected to be denied as not reasonable and necessary) means that you didn't issue an ABN, and you cannot bill the patient if Medicare denies the service.

"This means that an ABN should have been provided and signed, but it was not," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. "Before the service, the practice realized this and is letting Medicare know that the ABN was not signed and they will not balance bill the patient if and when the service is denied for medical necessity."