Here's Your Solution for Noncovered Procedures
Published on Wed Oct 12, 2005
Tell patients up front about possible financial responsibility
If you don't want to get caught absorbing the cost of an uncovered service that a patient requests or the surgeon recommends, you should reach for an advance beneficiary notice (ABN) and modifier GA.
Properly used, the ABN/modifier combination allows you to collect payment directly from the patient. Modifier GA Alerts Medicare of ABN The proper time to have the patient sign an ABN is before providing the service or procedure for which you want to recoup payment. 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, says Jeff Fulkerson, BA, CPC, CMC, certified coder at The Emory Clinic in Atlanta.
After the patient has signed the ABN, you must inform Medicare by appending modifier GA (Waiver of liability statement on file) to the CPT code describing the (suspected) noncovered service or procedure. When Medicare sees modifier GA, it will send an explanation of benefits (EOB) to the patient confirming that he is responsible for payment. If you don't append the modifier, Medicare will not inform the patient of his responsibility.
Example: A patient with laryngeal spasm (478.75) requests a Botox injection to combat his symptoms (for instance, 64999, Unlisted procedure, nervous system).
Get more info: See -Bill Botox Injections in Several Steps- later in this issue for further explanation on reporting Botox injections to the larynx.
This patient has already received two such injections in the past three months. Many insurers (including Medicare) limit the frequency of Botox treatments and will not pay for additional injections during a given time period without evidence of extenuating circumstances.
Because you are unsure whether Medicare will cover the procedure, you ask the patient to sign an ABN. The ABN outlines the service the surgeon will provide (laryngoscopy with Botox injection) and the reason Medicare may reject payment (excessive frequency). You would report 64999 with modifier GA appended.
The ABCs of ABNs An advance beneficiary notice is a written notice to a Medicare beneficiary that Medicare may not cover a particular service or procedure. By signing the waiver, the patient acknowledges that he will pay for the procedure or service if Medicare does not.
The ABN must clearly identify the service/procedure the surgeon plans to provide and state why Medicare may not provide coverage. The ABN affects only those services/procedures you-ve specifically listed. You should not give an ABN to a beneficiary if you have no specific, identifiable reason to believe Medicare will not pay. In all cases, you should provide the patient with a completed and signed copy of the ABN for his records.
Helpful hint: To obtain a standardized, sample ABN, visit the CMS [...]
