Question

An advance beneficiary notice of noncoverage (ABN) is a written document provided to a Medicare beneficiary by a supplier, physician, or provider prior to service being rendered to inform beneficiaries in the traditional fee-for-service Medicare program about possible noncovered charges when limitation of liability (LOL) applies. The ABN indicates that the service is unlikely to be reimbursed by Medicare, specifies why Medicare denial is anticipated, and requests the beneficiary to sign an agreement that guarantees personal payment for services. A beneficiary who signs an ABN agreement will be held responsible for payment of the bill if Medicare denies payment. ABNs should be generated whenever the supplier or provider believes that a claim for the services is likely to receive a Medicare medical necessity denial (a denial of otherwise covered services that were found to be not “reasonable and necessary”), or when the service would be considered custodial care. The provider is held liable for the service and cannot bill the Medicare administrative contractor (MAC) or the Medicare beneficiary unless the beneficiary signs an ABN, which makes the beneficiary liable for payment if they opt to receive the service after notice was provided. Providers must also have patients sign an ABN prior to providing preventative services that are usually covered by Medicare but will not be covered because the frequency of providing such services has been exceeded.

Zaza LeMore is an 85-year-old healthy female Medicare beneficiary who has been evaluated for possible cosmetic surgery on her eyelids, even though she is able to pass her vision exam. She states that her eyelids droop, she can’t get them to open wide enough, and they are a distraction to her. The plastic surgeon informs the patient that cosmetic surgery is not covered by Medicare. To proceed with the surgery, the patient must sign an Advanced Beneficiary Notice of noncoverage (ABN) so that Mrs. LeMore understands that she will be billed for all of the expenses associated with the surgery. The coder’s responsibility is to add modifier -GX to each code assigned for the procedures and services provided to the patient; thus, Ms. LeMore will be properly billed.

1. What is modifier -GX?

2. Is the planned surgery on Mrs. LeMore's eyelids considered cosmetic, experimental, or necessary? Will Medicare reimburse the provider for procedures and services performed? Under what circumstances might Medicare reimburse the provider for procedures and services performed? Explain.

3. What would happen if Mrs. LeMore refused to sign the ABN?

Answer 1

1.This is a term normally used in the service procedure of re imburment of medical expenditure , in order to keep the reimbursement procedure safe and comfort there should be certain mutual agreemnt, where by there will be a lot of rules and regulations associated with this services. Rules regrading coverage and non-coverage of services to patient he meets with.

Prior to denial of bill payment provider should give ABN to patient sign on it, in which a beneficiary is is not paid his expences by medicare and the liability for payment comes to benefciary himself.

Gx Modifier is a like a reporting method of these liabilities under this payer policy, where by a beneficiary came to know a situation beneficiary himself take payment risks.

2.she is able to pass the vision now, and cosmetic surgery is needed when this problems touches vision. This cosmetic surgery not covered by medicare and thus medicare does not re immburse the expenditure. Unless the ABN documents is signed by beneficery, there will be chance of payment to bills by service providers or by medicare.

3.if lee mors refuse to sign the ABN, no service may not be performed.