Three modifiers associated with advance beneficiary notice use; modifier 59 clarification
Q: When we submit a claim for which we have obtained a signed advance beneficiary notice (ABN) of non-coverage from a patient, which modifier should we use, and when should we use it?
The Centers for Medicare and Medicaid Services (CMS) recognizes three modifiers when an ABN is involved:
It is important to differentiate "not reasonable and medically necessary" denials from "non-covered" service denials. Non-covered services (that is, services excluded by law or under a non-benefit category) do not require that a waiver be signed, and the patient is responsible for payment. If the patient believes that a service may be covered and requests that a claim be submitted, however, or if the patient wishes to receive a formal CMS determination for consideration by a secondary insurer, then you must submit a claim for the non-covered service. In such instances, you may use the ABN to voluntarily notify CMS of financial liability; you no longer need to complete a notice of exclusions from Medicare benefits, or NEMB, form.
If you submit a claim for non-covered services or a procedure excluded from Medicare benefits, add a –GY modifier to the procedure code listed on the claim. Doing so assures CMS that the patient has acknowledged that he or she will be responsible for payment. CMS automatically will deny coverage of any claim submitted with the –GY modifier, so the use of this modifier may speed up the claims process and allow the patient to submit a claim to another carrier.
If you do not obtain a signed ABN form (for instance, if a patient refuses to sign the form, or if an emergency situation occurs) and you provide a service that you expect to be denied, you may apply the –GZ modifier to the claim.
MODIFIER –59 CLARIFICATION
Q: When is it appropriate to use the –59 modifier?
A: Use modifier –59 (distinct procedural service) to report a procedure or service that was distinct or independent from other services performed on the same day. Use it to identify non-evaluation and management procedures and services that normally are not reported together but are appropriate under the circumstances.
The CPT code description for this modifier specifically states: "Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual."
Remember, however, that the –59 modifier is the modifier of last resort and should be used only if no other modifier is appropriate. Overuse of the –59 modifier may trigger an audit by the payer.
For instance, a physician could excise one lesion that is 1.5 cm from an area of the extremity and perform a biopsy of another lesion on the same extremity but different location during the same visit. Biopsies are included in the excision of a lesion, so the –59 modifier must be used to indicate that the physician performed a distinct procedure on a separate lesion. Please see the chart below to see how a practice would bill in such a case.
The author is a compliance manager for Baptist Medical Associates in Louisville, Kentucky. Do you have a coding question for our experts? Send it to