Part B Insider (Multispecialty) Coding Alert

Published on Fri Nov 18, 2005 PDF

Hint:  ABN/modifier combo will guarantee payment--and protect you

When it comes to reimbursement for non-covered procedures, your best bet is to provide patients with notices that outline patients' responsiblitiy. These examples detail how modifiers GA (Waiver of liability statement on file) and GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefits) help you receive optimal payment from patients.

Example #1: A patient with chronic lower-back pain requests an epidural injection (62311--Injection, single [not via indwelling catheter], not including neurolytic substances ... lumbar, sacral [caudal]). He's already received six injections within the last year, which is the maximum number his Medicare carrier will reimburse without extenuating circumstances.

Good idea: Ask the patient to sign an ABN outlining the service the surgeon will provide and the reason Medicare may reject payment.

Result: The surgeon provides the injection, and you report the service using CPT 62311 with modifier GA. Since the patient exceeded the frequency guidelines, Medicare denies the claims and sends the patient an explanation of benefits (EOB) confirming that he is responsible for payment. If you don't append the modifier, Medicare will not inform the patient of his responsibility.

Example #2: A surgeon suggests that a patient receive an artificial disc to treat cervical spinal degeneration. But Medicare considers artificial disc placements suspect and won't pay for the procedures. The patient agrees to have the procedure.

Do this: For services that Medicare never covers, ask patients to sign a Notice of Exclusions from Medicare Benefits.

Result: Report 0090T (Total disc arthroplasty [artificial disc], anterior approach...) for the artificial disc and append modifier GY. Medicare will generate a denial notice, which patients can use to seek payment from secondary insurance.