Pathology/Lab Coding Alert

Question: When must I get a signed ABN for a noncovered test? I have read in authoritative sources that ABNs are not required for noncovered tests, and that ABNs are required for noncovered tests if the lab wants to bill the patient for the service. Which is correct?

North Carolina Subscriber
 
Answer: A signed advance beneficiary notice (ABN) must be on file to bill a patient for a service that would normally be covered but is denied by Medicare as medically unnecessary. For example, you need an ABN if a test is ordered in the absence of signs and symptoms of disease or if a test is ordered without a payable diagnosis code outlined in a carrier's local medical review policy. This is a different situation from a service that is statutorily noncovered by Medicare, such as checkups, most immunizations and screening tests. In the Medicare Payment Fee Schedule Database, which is available online at www.hcfa.gov/stats/cpt/rvudown.htm, the status indicator column identifies noncovered services with the letter "N." Medicare does not cover these tests as a matter of course, so an ABN is not needed.
 
The ABN alerts patients that Medicare most likely will not pay for a service because it is not considered reasonable and necessary in their particular situation. This only applies to services that would be covered by Medicare if they were ordered for a reason considered medically necessary.
 
CMS has announced that beginning Jan. 1, 2002, coders must use HCPCS modifiers -GA, -GY and -GZ when they bill Medicare carriers for services that are statutorily noncovered or for services not considered reasonable and necessary, whether or not a signed ABN has been acquired. Modifier -GY appended to a code indicates that it is a statutorily noncovered service. Use modifier -GZ when a service is expected to be denied as not reasonable and necessary, and the beneficiary has not signed an ABN. Use modifier -GA when a service is expected to be denied as not reasonable and necessary, and a signed ABN is on file. Information regarding these modifiers was announced in CMS program memorandum B-01-58, Sep. 25, 2001.
 
Answers to You Be the Coder and Reader Questions provided by Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Physician Coding & Compliance Consulting in Manassas, Va.