Anesthesia Coding Alert

Know when and how to rely on this tool ‧‧ but don't expect to always get paid

      When your anesthesiologist or pain management specialist performs a service Medicare doesn't usually reimburse, don't assume it's an automatic write-off. Keep an eye out for these potential roadblocks and file an advance beneficiary notice (ABN) up-front to switch the odds in your favor.

      What it is: An ABN is a written notice that informs the beneficiary (that is, the patient) that Medicare might not cover a particular service or procedure. Signing the waiver shows that the patient acknowledges he may have to pay for the procedure or service if Medicare does not -- if you document his treatment correctly, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher.

Why Won't Medicare Pay?

      If Medicare doesn't pay for a service your physician offers, the reason usually falls into one of two categories:

      • procedures that exceed Medicare's frequency guidelines

      • procedures that Medicare doesn't ever reimburse.

      To further confuse matters, you might run into situations when Medicare usually covers a service but considers it noncovered in other situations -- which means you would need an ABN.

      Over-the-limit procedures: Medicare only allows for a finite number of certain procedures per patient per time period. For example, Florida's Medicare carrier allows a repeat injection in the sacroiliac joint only if the first two injections relieved the patient's symptoms, says Myriam Nieves, CPC, ACS-PM, owner of Precision Medical Systems in Ft. Lauderdale, Fla. "Otherwise, the probability of the third injection providing relief is way too slim," she says. "They allow a maximum of three injections per year."

      Never-reimbursed procedures: Medicare simply doesn't cover some procedures, such as intradiscal electrothermal annuloplasty, or IDET (22526, Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level; and +22527, ... one or more additional levels [list separately in addition to code for primary procedure]). Although CPT 2007 includes new codes for IDET, Florida Medicare still considers IDET an experimental or investigational procedure, Nieves says. In these cases, you won't need a signed notification unless a secondary insurer is willing to pay.

      Gray-area procedures: Medicare reimburses for other procedures on a situational basis ‧‧ your physician might perform a service that Medicare covers in some instances but not in others. For example, Medicare reimburses for Hyalgan injections to the knee, but physicians might also administer Hyalgan injections to the shoulder because they've seen patients benefit from the treatment, Nieves says. "Because they are not using the product as indicated, this is a service that is covered under other circumstances but that would need an ABN if the patient wants to proceed with an injection in the shoulder," she says.

Why Try an ABN?

      Your physician has two main reasons to obtain a signed ABN from patients in certain circumstances:

      1. to ensure reimbursement for services provided but       deemed not covered by Medicare, and

      2. to reduce the risk of compliance implications associated with ABNs.

      When you present a patient with an ABN (and explain it), you help the patient decide whether he wants to proceed with a service even though he might have to pay for it. A signed ABN ensures that your physician will receive payment directly from the patient if Medicare refuses to pay.

      Best reason: Without a valid ABN, you cannot hold a Medicare patient responsible for the denied charges, leaving the bill in your physician's lap.

What Should an ABN Contain?

      A valid ABN must be Medicare-approved and must include:

      •  Patient name and Medicare identification number

      •  Name of items or services (prior to patient signature)

      •      Statement of provider's belief that Medicare won't    cover the service

      •      Statement of provider's specific reason(s) for believing Medicare will deny the claim as a procedure not

reasonable or medically necessary (writing "medically unnecessary" is insufficient)

      •  Patient's mark of one of the two boxes on the mandatory Medicare ABN form indicating that he either wants to receive the items/services or not

      •  Patient's dated signature.

      Extra detail: In addition, providers should ‧‧ but are not required to -- provide the patient with estimated costs of the potentially noncovered item or service.

      Keep it current: You should obtain a signed ABN for each recommended procedure or service that Medicare might not cover. There is no such thing as a "blanket ABN" that will cover all the procedures or services in a given visit -- this will not hold up to Medicare's scrutiny.

Request an ABN for Consults, Second Opinions

      You should obtain an ABN from a patient prior to rendering a service if you know that the patient is seeking a second opinion or confirmation of a diagnosis or treatment plan.

      Example: Mrs. Smith's physician recently diagnosed her with severe migraines. Mrs. Smith had an electroencephalogram (EEG), but her physician sends her to your anesthesiology pain clinic for a second opinion and more in-depth study before making any treatment decisions. Your anesthesiologist provides a full workup, including another EEG, and discusses possible outcomes with the patient. The ABN lets the patient know that she may be responsible for payment if the insurer deems the second EEG unnecessary.

      Many payers, including Medicare, have previously not covered confirmatory consultations because the insurers considered such second opinions -- especially when generated by the patient or patient's family -- a "duplication of services."

      This problem may continue to haunt physicians who provide second opinions for patients. Because another physician has already examined the patient and provided an opinion, the carrier may deem any attempt to re-examine the patient a duplication of services -- even if you bill the care as an office visit or inpatient or outpatient consultation.

      Caution: Sometimes patients don't tell physicians that they are seeking a second opinion, which means you could bill the visit in error. Help your physicians and office staff learn to verify these kinds of details with patients.

      Unusual service note: Medicare will not cover a procedure just because it has a CPT code. Consequently, physicians should obtain a signed ABN for any "non-mainstream" procedures, such as a telephone consultation (99371-99373, Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other healthcare professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists] ...) your pain management specialist might complete.

Modifiers Explain ABN Status  

      You should accompany any ABN claim with the correct code modifier so Medicare's explanation of benefits (EOB) will properly outline when the patient has to pay. Use the following descriptions to guide your modifier choice:

      • GA -- Waiver of liability statement on file. Use modifier GA when you've issued an ABN because you expect Medicare to deny the service as not medically necessary. This might include tests ordered without a payable diagnosis code or those ordered more frequently than covered (such as an EMG or a nerve conduction study).

      • GY -- Item or service statutorily excluded or does not meet the definition of any Medicare benefit. By law, Medicare excludes some medical treatments, such as many screening tests, and you might want to inform patients of this fact. Although you're not required to issue a notification (Notice of Exclusions from Medicare Benefits, or NEMB) for excluded procedures, doing so is a courtesy to the patient and may help you get paid. When you report modifier GY in these cases, Medicare will generate a denial notice that the patient can use to seek payment from secondary insurance ‧‧ helping the physician avoid unpaid claims.

            • GZ -- Item or service expected to be denied as not reasonable and necessary. Modifier GZ is bad news -- it indicates that you didn't issue an ABN when you should have. Therefore, you cannot bill the patient when Medicare denies payment. So why use GZ if you still won't get paid? Because you'll reduce the risk of fraud or abuse allegations when filing claims that are not medically necessary.