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Reporting Medicare for faster reimbursements with ABN modifiers

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.

When You Must Issue an ABN

You must issue an ABN when you expect Medicare may deny payment for an item or service because:

  • It is not considered reasonable and necessary under Medicare Program standards;
  • The care is considered custodial;
  • Outpatient therapy services are in excess of therapy cap amounts and do not qualify for a therapy cap exception;
  • A beneficiary is not terminally ill (for hospice providers only); or
  • A beneficiary is not homebound or there is no need for intermittent skilled nursing care (for home health services only).

Additional mandatory requirements apply to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. An ABN must be issued before DMEPOS suppliers furnish a beneficiary with an item or service that will not be paid for by Medicare because:

  • The provider violated the prohibition against unsolicited telephone contacts;
  • The supplier has not met supplier number requirements;
  • The supplier is a non-contract supplier furnishing an item listed in a competitive bidding area; or
  • Medicare requires an advance coverage determination, and the beneficiary wants the item or service before the advance coverage determination is made.

Claim Reporting Modifiers:-

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

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Persistence is required to taste the hassle free reimbursement

Couple of decades ago Healthcare physicians considered credentialing is the procedure for enrolment with an insurance company’s preferred provider.  Now a days, it’s mandatory than ever for physicians and healthcare providers including nurses, chiropractors, psychologists, counselors, LCSW’s and many others to be in network with insurance companies. This is a necessity because most people in the United States have health insurance than ever before.  And it’s necessary because people today demand their healthcare physicians accept their insurance.  Honestly saying, if a physician is not in network with a patient’s health insurance plan, provider is at risk of losing that potential patient to a competing practice.

Medical Credentialing referred to as insurance credentialing or provider enrollment is the process of becoming affiliated with an insurance company so that physician can accept third party reimbursement. Enrollment applications can be +40 pages long, and to ensure smooth processing there’s a lot of necessary, time consuming, follow-up.

The process of getting on insurance panels can be challenging and lengthy.  It normally takes between 2-3 months to submit the necessary paperwork and correspond with insurance companies’ credentialing departments, before getting approved to join an insurance panel.  Because of the large amount of paperwork and correspondence required, medical providers generally find the process to be very time consuming.

Medicare, State Medicaid, Private/Commercial Payer Management

  • New Payer Contracts or Enrollments
  • Re-Credentialing or Revalidations
  • Changes of Information- Ownership or Acquired Locations
  • NPI Enumeration / Management
  • Set up of EDI, EFT, ERA, PECOS Processes or Provider Web Portals
  • Payer Issue Liaison / Resolution with Payers
  • Local, State, Federal Licensure Procurement

Why not choose a professional credentialing service provider like Bristol Healthcare Services to complete your provider enrollment process.

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Watch for Bundles

Codes used for Percutaneous vertebroplasty include the two procedures frequently performed during the same session—imaging guidance and bone biopsy therefore you might not code individually for them at the same level.  If the medical provider performs bone biopsy at a level not addressed by the vertebroplasty, you may report biopsy alone with the 59 modifier appended to indicate the separate locations of the two procedures.

Additionally, percutaneous vertebroplasty includes moderate sedation, when performed, and may not be reported with fracture care codes 22310, 22315, 22325, or 22327 when performed at the same level.

Kyphoplasty Is Like Vertebroplasty additional lift

Percutaneous vertebral augmentation is a similar to vertebroplasty, but includes the use of an inflatable balloon to lift the damaged vertebra prior to methyl methacrylate injection.  To differentiate kyphoplasty from “standard” vertebroplasty look for evidence in the medical note for a mechanical device to augment vertebral height prior to injection of methyl methacrylate or poly methylmethacrylate bone cement, such as:

  • Balloon
  • Balloon assisted
  • Bone tamp
  • IBT or inflatable bone tamp
  • KyphX (a common brand name for the bone tamp)

CPT (Category I or Category III codes describe cervical kyphoplasty. To report cervical kyphoplasty, turn to 22899 Unlisted procedure, spine) includes three codes to describe kyphoplasty, which mirror the vertebroplasty codes:

Code 22513 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; relating to the thorax.

Code 22514 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g.,- kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

Code 22515 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

Code 22513 describes the initial vertebral body as treated in the thoracic area. Code 22514 describes the initial vertebral body as treated in the lumbar area. Select only one first level (either 22513 or 22514). For each additional vertebral body treated, beyond the first, report one unit of add-on 22515. Additional coding rules mimic those we applied, above, for vertebroplasty:

Code descriptor for 22513-22515 specify “unilateral and bilateral;” therefore, modifier 50 is not appropriate

Do not apply modifiers 51 or 59 to the add-on code 22515

Do not report bone biopsy (20225) performed at the same level(s) as kyphoplasty- Imaging guidance is included with 22513-22515

Do not use with 22513-22515 with 22310, 22315, 22325, or 22327, when perform at the same level

Moderate sedation is included with 22513-22515.

Make sure that no CPT Category I or Category III codes describe cervical kyphoplasty. To report cervical kyphoplasty, turn to 22899

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