Ophthalmology and Optometry Coding Alert

Proper G-modifier use unlocks otherwise denied reimbursement

When your office performs a service - even a noncovered procedure like cosmetic blepharoplasty or certain glaucoma screenings - you deserve payment for it. If you don't want to get caught absorbing the cost of services that a patient requests or the ophthalmologist recommends, and you know Medicare will not reimburse for a given service, you'd better use modifier -GA and reach for an advance beneficiary notice (ABN).

Properly used, the modifier/ABN combination allows you to collect payment for the ophthalmologist's effort directly from the patient.

Attach Modifier -GA to Alert Medicare of an ABN

The proper time to have the patient sign an ABN is before the ophthalmologist performs the service or procedure that you don't think the patient's carrier will reimburse. In some circumstances, you may not know for certain if Medicare will cover the service. When in doubt, protect yourself and request that the patient sign an ABN.

Rule: After you've secured a signed ABN from a Medicare patient, you must inform Medicare that you have this information on the CMS-1500 form by appending modifier -GA (Waiver of liability statement on file) to the appropriate CPT code. When Medicare sees the -GA modifier and does deny payment for the service, it will send an explanation of benefits (EOB) to the patient confirming that he is responsible for payment. If you fail to append the modifier, Medicare may not inform the patient of his responsibility.

Real-World Example: A Medicare patient requests a glaucoma screening. Medicare covers glaucoma screenings for high-risk patients, but the doctor isn't sure the patient will meet Medicare's description of "high risk." You have the patient sign an ABN and submit a claim of G0117-GA (Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist; Waiver of liability statement on file). Medicare denies the claim and sends an EOB to the patient, explaining that he is not considered at high risk for glaucoma.

Use Modifier -GY for Statutorily Noncovered Services

An ABN is not necessary when the surgeon performs procedures or services that Medicare never covers (such as vision correction for refractive error). The doctor may still ask the patient to sign an ABN to verify that he is responsible for the service's cost. And, some patients want the physician to submit a claim for noncovered services in hopes of receiving coverage from a secondary insurer.

In such cases, you should report the appropriate CPT code for the ophthalmologist's services with modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) appended in addition to -GA. Medicare will generate a denial notice for the claim, which the patient may use to seek payment from a  secondary insurance.

Real-World Example: A 55-year old male wants to get rid of the puffy bags under his eyes. The ophthalmologist performs blepharoplasty. The patient knows that it will be denied as cosmetic, but he needs the denial to seek reimbursement from a private carrier. You ask the patient to sign an ABN and collect payment up-front. You submit a claim of 15823-50-GA-GY (Blepharoplasty, upper eyelid; with excessive skin weighting down lid; Bilateral procedure; Waiver of liability statement on file; Item or service statutorily excluded or does not meet the definition of any Medicare benefit), and the patient seeks reimbursement on his own afterward.

Use Modifier -GZ When Medical Necessity Is Shaky

Use modifier -GZ (Item or service expected to be denied as not reasonable and necessary) in addition to modifier -GA when a service is provided that the physician does not think the insurer will cover due to lack of proven medical necessity. For example, a physician may perform a testing procedure due to a symptom the patient is reporting, but there are no physical findings to support the complaint.

"We refer to this type of testing as 'ruling out' a possible problem," says Raequell Duran, president of Practice Solutions, a coding, compliance and reimbursement consulting firm specializing in ophthalmology, based in Santa Barbara, Calif.

Real-World Example: A patient complains of vitreous floaters. Though he knows that the patient's carrier does not think vitreous floaters prove medical necessity for the testing procedure, the doctor performs a fluorescein angiography to rule out possible problems.

The patient fills out an ABN, and you submit a claim of 92235-GA-GZ (Fluorescein angiography [includes multiframe imaging] with interpretation and report).