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Monthly Archives: June 2016

How to report Medicare related to Advance Beneficiary Notifications Modifiers

CMS’ coding modifiers are not always used to report clinical components of a service.  Sometimes they can be used in a hospital to provide information about how a service relates to Medicare coverage policies.

Modifier -GA is used to indicate that a waiver of liability statement that is required by the payer is on file.

Modifier -GX is used to describe a voluntary waiver of liability.

Modifier -GY is used to describe an item or service that is statutorily excluded or that does not meet the definition of any Medicare benefit.

Modifier -GZ is used to describe an item or service expected to be denied as not reasonable and necessary.

Why and When is Advance Beneficiary Notifications

An Advance Beneficiary Notice (ABN) is a notice that the provider must provide to a Medicare beneficiary before providing certain items or services.

You believe Medicare may not pay for an item or service

Medicare usually covers the item or service

Medicare may not consider the item or service medically reasonable and necessary

for this patient in this particular instance

ABNs are issued only to those patients who are enrolled in Original Fee-For-Service Medicare.  These documents allow patients to make informed decisions about whether to receive services and to accept financial responsibility for those services if Medicare does not pay for them.  The ABN serves as proof that the beneficiary knew prior to receiving the service that Medicare might not pay for it.

This ABN can also be used as a voluntary notice to alert patients of their financial liability prior to providing medical services that Medicare never covers.  An ABN is not required to bill a patient for an item or service that is not a Medicare benefit and is never covered.

There are exceptions to this rule, however: ABNs may be routinely issued in the following circumstances:

Experimental items and services

Items and services with frequency limitations for coverage

Medical equipment and supplies denied because the supplies had no supplier number or the supplier made an unsolicited telephone contact

Services that are always denied for medical necessity

Modifier -GA claims payment and processing

Medicare systems will automatically deny lines submitted with the -GA modifier and covered charges on institutional claims

Medicare systems will assign beneficiary liability to claims automatically denied when the -GA modifier is present

Medicare will use claim adjustment reason code 50 when denying lines due to the presence of the -GA modifier

Hospitals must issue an ABN to the beneficiary prior to providing care that Medicare may not cover because it is not medically reasonable and necessary in this particular case

Medicare permits hospitals to bill the patient if the patient has signed a valid ABN indicating his or her choice to get the item or service and accept financial liability

If the hospital does not issue an ABN or Medicare finds the ABN invalid, that patient may not be billed

Hospitals may not use ABNs to charge for a component of a service when Medicare makes full payment through a bundled payment (e.g., a fluoroscopy that is bundled into an injection procedure may not be billed to the patient since its payment is included in reimbursement for the injection)

Medicare prohibits providers from using an ABN to transfer liability to the beneficiary when Medicare would otherwise pay for items and services

When you issue the ABN as a voluntary notice (modifier -GX), the beneficiary does not check an option box or sign and date the notice

The ABN is issued for items and services covered under Part B

Determine what new evolving technologies may or may not be coded in 2016.

CPT Category III codes mostly do not have a customary payment amount per CPT guidelines, however, if a Category III code is available, you must report it instead of a Category I unlisted procedure code.

Find below Category III code changes for 2016.

0381T External heart rate and 3-axis accelerometer data recording up to 14 days

0382T review and interpretation only

0383T External heart rate and 3-axis accelerometer data recording from 15 to 30 days

0384T review and interpretation only

0385T External heart rate and 3-axis accelerometer data recording more than 30 days

0386T review and interpretation only

Leadless Pacemakers

There are five new codes to describe services related to permanent leadless pacemakers:

0387T Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular

0388T Transcatheter removal of permanent leadless pacemaker, ventricular

0389T Programming device evaluation in person with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system

0390T Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system

0391T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system

CPT® Changes 2016 advises, “Existing CPT codes only addressed procedures for traditional pacemaker systems and did not adequately describe the procedure of implanting a leadless pacemaker. Therefore, these codes have been established to report leadless and pocketless system procedures.”

Esophageal Sphincter Augmentation

Esophageal sphincter augmentation is performed for treatment of gastoesophageal reflux disease (GERD). The device employs magnets, placed around the gastroesophageal junction. The attraction of opposing magnets narrows the opening, but allows food to pass when the patient swallows.

0392T Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band)

0393T Removal of esophageal sphincter augmentation device

Experts LRN’s seamless effort Overturned denied claims for payment.

Bristol healthcare services partnered a FL Medical billing company this May 2016 to clear a huge backlog of +18,000 accounts to move for the next level.  We were able to identify most of the claims denied resulting insufficient medical notes, we know these denials are recoverable through the filing of effective appeals.  With experts in mind Bristol Healthcare Services partnered with remote registered nurse to navigate these complex appeals process for them to overturn denied claims for payment and to reduce unnecessary write-offs.  Our onsite licensed RN’s carefully review medical records to effectively prepared and sent appeals from the start to resolution.  We acted as an extension of the medical practice along with the RN’s using their working knowledge of various payer authorization requirements, medical criteria and protocols necessary to make the case for successful appeals.  In addition to clinical experience, our team offered follow-up and support during the adjudication process as needed to overturn even difficult denied claims paid.