Part B Insider (Multispecialty) Coding Alert

Published on Sun Apr 23, 2006 PDF

Helpful hint:  No ABN necessary

When your ophthalmologist performs a service that Medicare never covers, do you attach modifier GA to your CPT code? If so, you're making a big mistake.

The key word here is "never." When your ophthalmologist performs a service or procedure that Medicare never covers--such as refractions or refractive surgery--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. This modifier automatically prompts Medicare to generate a denial notice for the claim, which the patient may use to seek payment from secondary insurance.

Remember: You don't need to ask the patient to sign an advance beneficiary notice (ABN) when the ophthalmologist performs a never-covered procedure. However, to verify that the patient is responsible for the service's cost, the physician may provide a notice of exclusion from Medicare benefits (NEMB). Patients may even request that the physician submit a claim for never-covered services in hopes of receiving coverage from a secondary insurer.

Example: An ophthalmologist who has established a separate charge for 92015 (Determination of refractive state) performs a refraction on a patient. The patient needs a denial from Medicare so that his secondary insurance will cover the service. Report 92015-GY to Medicare.

Another way: Modifier GY keeps your records accurate and helps speed up Medicare's denial process, but it's not mandatory. If using the modifier complicates payment from the secondary insurer, don't use it, says Elizabeth Borgen, coding and billing specialist for the North Dakota Eye Clinic and Surgery Center in Grand Forks.

In one case, "the secondary didn't understand the Medicare denials with modifier GY, and I had a mess," Burgin relates. Her solution: submitting 92015 without modifiers to Medicare, waiting for their denial, and then submitting it to the secondary insurer.

Key: Modifier GY is only appropriate for services Medicare never covers. Check the status code in the Physician Fee Schedule Database--if the code is "N," Medicare never covers that service. These codes are also specially marked in many CPT manuals.

Bonus resource: You can find a sample NEMB at the CMS Web site www.cms.hhs.gov/medicare/bni/01_overview.asp.