ABN/modifiers/moderate sedation

jessicahocker

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I understand the following to be a question to and response from the AMA about time in moderate sedation:
_______________________________________________________________________________________________________________________
Question: Is it appropriate to report the moderate (conscious) sedation codes for the first 30 minutes of intraservice time if only 10 minutes of moderate sedation services are provided?

Answer: No. The standards for time measurement provided in the Introduction of the CPT 2011 codebook shall apply unless there are code or code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary. As there are no code or code-range-specific guidelines for the moderate (conscious) sedation codes, the general guidelines are to be applied. A unit of time is attained when the midpoint has been passed. Therefore, in order to report a code with a unit of time of 30 minutes, 16 minutes or more of the service described by the code must be provided. If the time threshold has not been met, then the code is not reportable.
_______________________________________________________________________________________________________________________

Hypothetically, a patient is scheduled for a procedure, they are asked if they request sedation for this procedure and they are informed that their insurance may not cover the sedation if they are sedated for less than 16 minutes. If the patient has Medicare, they sign an ABN. The ABN gives a specific charge for sedation.

1. Does the ABN need to state both that there may not be a Medicare approved diagnosis for this code and also that the sedation may not meet the amount of time required to bill Medicare?

**Example: The patient has the procedure, is consciously sedated because of their fear of injections, but is only sedated for 15 minutes.

2. Can the provider bill the patient the specified charge for sedation for the 15 minutes of sedation that we have administered for their fear of injections?]

**Continuing the example: The patient has selected Option 1 on the ABN. They want the sedation listed above. They pay the provider for the sedation, but they also want Medicare billed for an official decision on payment. They are informed they will receive a Medicare Summary Notice with this official decision. They may appeal to Medicare by following the directions on the MSN. If Medicare does pay, the provider will refund any payment she made to the provider for the sedation, less any co-pays or deductibles.

3. Could, should, must the provider bill Medicare for the 99144 that was not 16 minutes, but only 15 minutes?

4. Is there a Medicare Modifier that would be used in this situation?
Would GA be used to indicate that the patient has elected to pay for sedation if Medicare does not cover it?
Would GZ be used because the time in sedation did not reach 16 minutes?

5. What is the purpose of a GY modifier? I understand that its explanation is “Item or Service Expected to Be Denied as Not Reasonable and Necessary,” but I read that it should be applied when an ABN may be required, but was not obtained. This sounds to me like, “I know this is going to get denied because we didn’t have the patient sign an ABN, so we’re going to write it off, but for some reason we’re billing you anyway?” Is there a better explanation for this?

Thank you for your help.
 

thomas7331

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The instance you are describing, sedation of less than 16 minutes, would not be appropriate for the use of an ABN. The purpose of the ABN is to notify patient that a service may not be covered 'in this instance', for example due to medical necessity or frequency limitations of Medicare coverage guidelines. In this case, coding instructions are that this CPT code 'cannot be reported' if the time requirement is not met - it is not a case of something not being a covered benefit by the payer. It could be considered a false and potentially fraudulent claim to report 99144 in this instance because the code is not supported by the service rendered and using the ABN to get around coding limitations could get the practice into trouble - I'd highly recommend against this.

As an example of correct use of an ABN, if a service is covered once per year but the provider recommends it more frequently than this and the patient agrees, you are required to have a signed ABN in order to hold the patient liable for the charge. On the form, the patient has the option of requesting that the service be billed to Medicare, and if so, this is where the GA modifier would be used, and the EOB will show that the patient owes the provider. If the provider does not get an ABN, use modifier GZ to make it clear that the expectation is for a denial and the patient will not be responsible. For services that are completely excluded from coverage, such as an annual physical exam or a hearing aid, the ABN is voluntary and providers may use it as a courtesy to help make the patient aware that they will be responsible for payment and modifier GY is used in this case.

The rules can be pretty confusing but the Medicare manuals give detailed instructions on how and when the ABN should be used. I'd recommend reading through the material on your Medicare carrier's web site carefully since it can be an area that can cause compliance problems if not followed. Hope this helps some.
 

jessicahocker

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Thank you so much, Thomas, for your response! I just have a couple more questions.

If an anesthesiologist doesn't necessarily know that the sedation will take more or less time than is required to bill the insurance, is having an ABN for a possible non-covered diagnosis on hand unethical?

Would it be appropriate to bill the patient for the requested sedation since the resources for this were provided at their request (even though it aids in providing the best procedure possible)- and would a "non-Medicare notice of self pay sedation if sedation were not to last for 16 minutes" (or something stated a bit more eloquently) be the proper course?

Thank you again.
 
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