I believe in CYA (cover your ....), so I have all pts sign something if we expect it to be denied. This is NOT required. Lemme clarify.

We have two situations, "not reasonable and necessary" and "not a covered benefit".

Not Reasonable and Necessary: A service that is normally covered, but because of circumstances, expects to be denied as not reasonable and necessary. Pap smears every 2 months (pap smears are covered, just not this often); two office visits in one day (OV is covered, not this often); weekly psychotherapy for six months with a minor stress diagnosis, etc.

Not A Covered Benefit: A service that is never covered under any circumstances. Examples: Ear Piercing, House Cleaning by a Home Health Aide, Medical Care Performed by a Family Member, Plastic Surgery for Cosmetic Reasons, Removal of Skin Tags (with no symptoms), etc.

Use either GA or GZ for Not Reas. GZ means basically someone screwed up cuz you should have gotten the ABN signed. GA means you did it right.

Use GY for Not Covered. Although an ABN is not required, whenever a situation called for a GY modifier, we would have the patient sign our own version of the ABN, that states the services they have requested are, in our opinion, NEVER covered under their medicare plan, but that we will bill Medicare on their behalf, and because we expect it to be denied, they are fully responsible for the charges at the time of service. We incorporated the wording into the regular ABN so we would only have one form.

Sharon