MD - Health Care Compliance Association

Improving revenue through compliance ...continued from page 9
nessed the refusal to sign, sign the form. The
witness can write “pt. refused to sign” on the
form and then sign and date it themselves.
This makes the form as legally binding as if
the patient had signed the form.
Initial audit results
Our initial audit, which was run on both
medical sites and billing clients, yielded poor
results. All site/billing clients failed the audit.
Some of the problems encountered included:
■ Not using federal form CMS-R-131 G
■ Unable to produce the ABN
■ Essential field elements not completed
■ No options checked off
■ Estimated cost not filled in
■ Form not signed or not dated
As a corrective action plan, an aggressive
mandatory training program schedule was
made and all sites, along with numerous
clients, were trained on the proper use of
ABNs. A reference guide was developed as a
tool to help in the decision-making of when
to use an ABN and the corresponding modifiers.
Reminder stickers for the –GA and
–GY modifiers were given to data entry personnel
to place on their monitors.
Use of Modifiers –GA & –GY
One of the problems revealed by the audit
was that data entry staff did not know how
or when to append the appropriate modifiers.
Since most of the sites and many of the
clients perform this function at the medical
office, it was imperative to educate these staff
members on the modifiers.
The –GA modifier signifies that an ABN has
been signed. Any service provided where
medical necessity may be in question should
have an ABN signed and be billed with the
–GA (see Figure 1: ABN Reference
Guide on page 13). An example would be
an EKG performed as part of a preventive
care visit for a patient with hypertension.
The fact that the patient has hypertension as
a secondary diagnosis (with the primary diagnosis
as V70.0 routine PE) may be enough
for Medicare to reimburse for the EKG.
However, since it is being done as part of a
routine PE, it may not be covered. Another
example would be a patient receiving a pneumonia
vaccine. This particular vaccine is a
once-in-a-lifetime benefit under Medicare.
So, if the patient is 80 and had a pneumonia
vaccine when he or she was 65, or had one
previously from another provider and doesn’t
remember, the claim will be denied.
Therefore, this vaccine should also have an
ABN obtained and be billed with the –GA
modifier. In this case, it is more than the
service that would be given away should it
turn out that the patient already received the
once-in-a-lifetime—the initial outlay of cash
by the practice for purchasing the vaccine
would also be lost. For vaccines and injectables,
the administration for the vaccine
should also be billed with the –GA modifier.
Any exams, tests, or services that have frequency
requirements should also have an
ABN obtained to safeguard your ability to
balance bill if the claim is denied. An example
of such a situation would be a screening
pelvic/breast exam (G0101) and pap smear
(Q0091). This is a covered benefit only every
two years. If you are performing this annually
or the patient had it done elsewhere and
you don’t know about it, then you will lose
the revenue without a signed ABN and claim
billed with the –GA.
An ABN does not have to be completed for
services that are statutorily non-covered (see
Figure 1 on page 13). In the situations
where statutorily non-covered services are
performed, the data entry person needs to
append the –GY modifier, signifying that it
is excluded as a Medicare benefit. Using the
–GY will fulfill the “demand bill” requirement
and allow a medical office to collect
payment for the service(s) at the time of service
(just as you would collect a co-payment
on the same day as a visit). Claims billed
with the –GY will be denied by Medicare
and allow balance-billing the patient if payment
was not collected up-front. An example
would be for a routine or annual physical.
This service is statutorily non-covered by
Medicare, so you would bill the 99387 (new
patient) or 99397 (established) with the –GY
modifier and collect payment up-front. The
caveats here are (1) if the patient has additional
commercial insurance, the preventive
care visit may be covered, so wait for a denial
before balance-billing, and (2) although the
PE itself is non-covered, you will still need to
obtain an ABN for any screening tests that
are performed as part of the physical i.e.,
EKG, PPD, vaccines etc.
Re-audit in six months
After the staffs received their initial training,
a second audit was run at 6 months.
Expectations were high that there would be
vast improvements and that everyone would
pass. Unfortunately, this did not happen.
However, there were improvements in that
the –GA modifier was being used more often
and offices were able to produce a corresponding
ABN in most cases.
Phase 2 of the ABN training was now in
effect. All errors from the second ABN audit
were compiled and analyzed. They were broken
down into two areas: form completion
and modifier use. With the details of the
audit errors, an ABN Refresher Program was
developed.
The errors included:
■ Some sites still could not produce an
ABN when the –GA modifier was used
■ ABNs were used for covered services and
sick visits
January 2006
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