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 [...]