First, keep in mind that Medicare only covers a bone-mass measurement for a beneficiary once every two years. The physician or ancillary staff will need to have the patient sign an Advance Beneficiary Notice (ABN) to ensure reimbursement before the patient leaves the office.
Physicians are required to have a signed ABN in the medical record of each patient that has a reasonable and necessary service. The above scenario is deemed reasonable and necessary and should be coded with the correct CPT code appended by a modifier, -GA. The -GA modifier will notify CMS that you have a signed and dated ABN on file for that service and the physician can bill the patient if Medicare does not reimburse for the service. If you do not have a signed ABN, then the CPT code should be appended with a -GZ.
Remember that the patient should not be billed for a denied Medicare-covered service unless an ABN has been signed or there is a statement in the medical record indicating that the patient refused to sign the ABN.
April’s coding question: Paul, a new 50-year-old patient, comes in with a referral from his primary care physician. Do you code this as new patient visit or consultation visit?
The correct answer is: It would depend on whether the primary care physician is requesting your medical opinion or just referring the patient for insurance reasons. If the primary care physician is requesting your medical opinion and you have properly documented this in the patient’s medical records, you can bill for a consultation. If this is only a referral request because of an insurance guideline then it will have to be billed as a new patient visit. Visit the Practice Support section of www.rheumatology.org for more documentation aids.
