No ABN w/ Medicare primary Medicaid 2ndary

Birdie625

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Please bear with me as I try to word this.....i understand E/M codes to be a 'statutorily covered' service of Medicare. A diagnosis might make it non medically necesary. We should get an ABN stating Medicare might deny due to lack of necessity. If no ABN we should append modifier GZ.

Our offices are billing without any modifiers. Medicare denies and puts a PR (pat.responsible) reason on EOB. We bill medicaid for balance (state of VT and MAC is NGS).

"My" thinking is IF we used the mod GZ (no ABN on file) medicare would deny and we would do a CO instead.

Because we are not using modifiers is: 1) wrong (??) and 2) is skewing where liability lies. I am being told to bill Medicaid for balance. Im stuck in thinking 'but if we appended GZ, NGS probably would have denied to provider liable and we should not then bill Medicaid".

Am I thinking this correctly??

Apologies for the kryptic-ness in my typing....and thank you in advance for any comments.
 

mitchellde

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You do not get ABNs for E&M services because there is no way to know prior to the visit what level of service will be needed. If you E&M is being denied it is more than likely some other reason. Are you using invalid do codes or unspecified codes? What do the denials state as the reason for the denial? It is unusually for an E&M to be put to patient responsibility in a provider office by Medicare. What is your specialty.
 

thomas7331

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I've never heard of this situation applying to an E&M service - I don't know of a Medicare payer that applies medical necessity rules to E&M codes for specific diagnosis codes, so I'm a little confused by your question. When you say Medicare is denying with a PR but no modifiers were used, what is the denial for? There are other reasons besides medical necessity that a patient might be liable for the charge that have nothing to do with medical necessity and for which no ABN is required in order to bill the patient or the secondary insurance.

The ABN process to avoid provider liability usually applies to services that have a specific LCD that governs and limits the diagnosis codes for which the service can be paid. The GZ modifier is used for cases 'provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy', meaning there is a specific published policy that defines the service as not covered for a particular diagnosis. It's not for a generalized expectation that something might be determined to be medically unnecessary. So for services that fall under an LCD, with an ABN and a GA modifier you'll get a PR-50 denial whereas without an ABN, it would be a CO-50 denial, and that should happen with or without the GZ modifier. Leaving off the GZ modifier won't automatically make it patient responsibility - the GZ modifier is mainly informational and allows the Medicare payers to issue the denial without having to do a more detailed medical review of the claim.
 

Birdie625

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Holyoke
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Thank you all for your replies. 1) I too was thinking it would be kind of odd to get ABN for every EM visit. 2) the denial is PR 204 This service/equipment/drug is not covered under the patient’s current benefit plan. 3) the dx I dont recall, but I think it was for a screening for Hep. Or HIV, I dont remember but it was a screening type dx. 4) i have since found on our VT site a blurb stating ...when Mcare denies (in this case, denied and put to pt. PR 204 ( the pt does have part b)) the provider will submit the 1500 along with the Mcare EOB for consideration.... We normally have to do a certain form to Medicaid stating Medicare put to pt. ded or coins, which this particular denial was not falling under.

I much appreciate the info thus provided. I will appreciate any more "teaching" comments/info if provided. The fact that I am missing the EOB reason code was huge. I will look into learning more about the different codes and meanings. Thank you all much. Cam. ( ps we are a provider based multi specialty group)
 
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mitchellde

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You do not use screening dx codes with E&M codes, so that is most likely the problem. The coding guidelines tell you that you use the screening dx codes only for the screening procedure codes. so for a screening lab you need to match up to a lab draw and a lab code not an E&M code.
 

Birdie625

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Holyoke
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You do not use screening dx codes with E&M codes, so that is most likely the problem. The coding guidelines tell you that you use the screening dx codes only for the screening procedure codes. so for a screening lab you need to match up to a lab draw and a lab code not an E&M code.

Thank you again! ?
 
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