Anesthesia Coding Alert

Follow these steps to use the right form every time

Ideally, Medicare reimburses your anesthesiologist or pain specialist for all the services he provides--but when it doesn't, automatically relying on an advance beneficiary notice (ABN) to gain patient payment isn't always your best bet.

The answer depends on the situation, so follow these easy steps to correctly handle carrier-denied claims.

Learn Your Terminology

An ABN often comes in handy when you expect Medicare to deny payment, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher. This can include services such as pain management injections that surpass the standard frequency limit. When the patient signs an ABN prior to the procedure, she accepts payment responsibility for whatever Medicare does not reimburse. But an ABN isn't always the most appropriate document for procedures not covered by Medicare.

Why that is: Because ABNs are only for procedures that Medicare might not cover, you should not use them for procedures that Medicare excludes from payment. The Notice of Exclusions from Medicare Benefits (NEMB) states clearly that Medicare definitely doesn't cover a procedure regardless of the physician's specialty.

These situations could include telephone conferences, patient fees for not keeping an appointment, or maybe even cosmetic Botox procedures, says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside. Unlike the mandatory ABN form, providers may use notices of their own design rather than the Medicare NEMB form.

CMS recommends NEMBs as a courtesy to the patient, although Medicare does not require them. Having the patient sign the NEMB will remind him that Medicare will not cover the procedure, and he will be billed for it.

But what if the patient signs the ABN, the physician performs the procedure, and Medicare refuses payment? What now?

You might be in the habit of obtaining ABNs for noncovered services, but having that piece of paper doesn't ensure your practice's compensation. Streamline the steps between ABNs and money in the bank by checking two details:

1. Know Who's Liable

Understanding the regulations dictating how to get ABNs from patients is helpful, but it isn't all you need to know. You should also know how these regulations translate into payments--or don't.

Pitfall: Don't make the mistake of assuming that once a patient signs an ABN, you're going to get paid. Depending on the type of liability provision the patient falls under, the ABN may not mean anything other than notification of noncovered services.

2. Lock in Necessity

Deciding what meets medical-necessity requirements for an ABN service isn't always easy. CMS defines medical necessity as "the determination of a service that is reasonable and necessary for the diagnosis of illness or injury, or treatment of a malformed body member."

And once the services meet that condition, you might still have to navigate through a maze of other regulations, such as local coverage determinations (LCDs) and national coverage determinations (NCDs).

Use these steps to decide whether the service fits the carrier's medical-necessity rules:

• Look at the physician's order or patient's prescription to find out whether that test or service has an NCD and/or LCD. If there are no coverage limitations, the patient doesn't need an ABN, and you're in the clear.

• If you find a relevant NCD and/or LCD and discover that the service or test does have limited coverage, review the diagnosis or signs and symptoms that prompted the physician to order the test, and decide whether the policy covers that indication.

• If you find that the service does not meet the medical-necessity requirements, and the signs and symptoms or diagnosis is not on the covered list, you should have the patient complete an ABN.

Tip: Be sure to check for frequency limitations on tests. If an LCD places a limitation on a service and the patient exceeds it, you'll need to issue an ABN.

Hint: Keep in mind that Medicare usually relies on the primary diagnosis code to make the appropriate medical-necessity determination.

ABNs Protect Patients, Too

 ABNs help the patient understand his options. Once you have completed the ABN and discussed it with the patient, he can 1) sign the ABN and assume financial responsibility for the procedure in question 2) cancel the procedure 3) reschedule the procedure or service for a future date when he can afford it, or when Medicare may cover the procedure or 4) refuse to sign the ABN and request that the physician perform the procedure anyway.

How to Move Forward--Without a Signature

 What if the patient refuses to sign? The physician's obligation under Medicare is to notify the patient that a procedure might not be covered. Reviewing the ABN with the patient fulfills this obligation. Therefore, your physician can still bill the patient for any procedures Medicare denies.

Documentation is key in this situation. Even if the patient refuses to sign the ABN, the provider should indicate on the ABN that he addressed the issue with the patient but that the patient refused to sign and still requested the procedure. Have two witnesses among the physician's staff sign and date the refusal, and keep this document in the patient's file. Then submit a claim to Medicare as if you had a signed ABN to continue the reimbursement process.

What happens next: After you submit a claim for services for which the patient has signed an ABN, the patient receives an explanation of benefits (EOB) from Medicare stating that it denied payment for the procedure(s) in question and why and that the patient is responsible for the cost of the items/services. Patients can then contact their local Medicare carrier for more information about the claim.

Note: For more on ABNs, see "Save Time and Trouble by Using ABNs Correctly" in the May 2007 Anesthesia & Pain Management Coding Alert.