Part B Insider (Multispecialty) Coding Alert

Published on Wed Jun 01, 2011 PDF

Following are examples of when and how to properly use ABNs.

• Because of personal concerns, a patient asks that a urologist perform a second screening prostatespecific antigen (PSA) determination, although he had one within the last year.

By statute, Medicare will only reimburse one screening PSA (G0103) annually. Medicare most likely won't pay on this second repeat study. You should have the patient sign an ABN to ensure that he understands that he will most likely be financially responsible for this second screening PSA.

• A patient with laryngeal spasm requests a botulinum injection to combat his symptoms. This patient has already received one chemodenervation injection in the past two months. Medicare often limits the frequency of botulinum 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 physician will provide(laryngoscopy with Botox injection) and the reason Medicare may reject payment (excessive frequency). You would report 64613 with modifier GA (Waiver of liability statement on file) appended.

• A patient with chronic lower-back pain requests an epidural injection (62311). This patient has already received six such injections in the past 12 months -- the maximum number his Medicare carrier will reimburse in a one-year period without extenuating circumstances.

Because you are unsure if Medicare will cover the procedure, you ask the patient to sign an ABN. The surgeon provides the injection, and you report the service using 62311 with modifier GA appended. In this case, because the patient has exceeded the frequency guidelines, Medicare denies the claim and sends the patient an EOB.