| Auditors will now request ABNs |
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Mandatory Use of GA - GX modifiers for ABN was added to Chapter 3 of the Medicare Program Integrity Manual (Section 3.15). This addition directs contractors to request, as part of the Additional Documentation Requests (ADRs), required ABNs when performing a complex medical record review on all claims. The modifiers have been added to distinguish between "required notices" and those that are "voluntarily given" by the provider to the patient.
The "GA" modifier is used when the services are normally payable under Medicare but may not be paid as a necessary service in this circumstance. The objective of the ABN is to show that those services listed on the notice "may be denied" by Medicare, that the patient has elected to receive the services and that they have made an "informed decision" to personally pay for them if they are denied. If the services are denied, Medicare will assign the liability for payment to the patient using the PR-50 adjustment reason code. This permits collection from the patient but ONLY if you have a valid ABN on file. If you assign the "GA" modifier and do NOT have the ABN in the file, the contractor's auditors have a cause of action since those services would have been legitimately assigned to the "contractual obligations" denial where you would NOT be permitted to collect the charges from the patient. (ie-CO-50).
The "GX" Modifier is used to indicate to Medicare that you issued a "voluntary" notice to the patient that the services "are NOT" ever covered by Medicare (excluded by statute) and that they will need to accept personal responsibility for payment. The modifier should only be used IF you have the ABN in your file. Use of the "GX" modifier will formally assign the liability to the patient and provide you a valid denial and assignment of that liability to the patient for future collection efforts from the patient or a secondary where billing those same services without a modifier would normally cause a "CO" denial.
Modifier "GY" (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) is permitted and typically should be used on the same line item as the "GX". Reporting it with the "GZ" (item or service expected to be denied as not reasonable and necessary) however will cause the entire claim to be "rejected" and returned un-processed. You should not use the "GX" with payment liability modifiers where another modifier sets another liability provisions. EY (no doctor's order on file), -GA, -GL (medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN) . |
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Be prepared for requests for prescriptions for over the counter drugs.
Consumers with flexible spending accounts (FSAs), in which pre-tax income can be used for medical purchases, can no longer spend the money on over-the-counter drugs, including ones that treat fevers or allergies and acne, unless they have a doctor's prescription. The new restrictions, which lawmakers included in the health overhaul to raise more revenue, also apply to health reimbursement arrangements (HRAs), health savings accounts (HSAs) and Archer medical savings accounts (MSAs). Starting this year, those with HSA or MSA accounts who spend money inappropriately will not only owe taxes on it, but also face a tax penalty of 20 percent, double what it was. For all pre-tax accounts, medical devices such as eyeglasses and crutches, and co-pays and deductibles still qualify for the accounts. Insulin obtained without a prescription is also eligible.
If your medical file reveals that the patient is taking the OTC meds, you can write the prescription based on that information "if you wish". If the patient has no history or using that medication, you can also require them to come in for an evaluation at your normal E&M fees. |
