Gastroenterology Coding Alert

Notices are required before billing a patient the remainder of a Medicare bill

CPT 2004 may have provided a code to use when a patient comes in for the Stretta procedure, but if you don't obtain an advance beneficiary notice (ABN) before starting the treatment, your office will be responsible for any part of the bill Medicare won't cover.

The Stretta procedure, which is gaining acceptance as a treatment for gastroesophageal reflux disease (GERD), should be reported using 0057T (Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease).

Many Carriers Won't Pay

However, Stretta is still considered an investigational procedure, and many carriers, including Medicare, may not reimburse fully for it - if at all.

Before the Stretta treatment is administered, the physician must inform the patient that he may be responsible for the remainder of the bill if Medicare refuses payment. Otherwise, you can't bill the patient for any part of the bill Medicare doesn't cover, which means your office will be forking over the difference.

ABN Gives Patient ABCs of Situation

That's where an ABN comes in, according to Cecile M. Katzoff, MGA, vice president for consulting services at the American Gastroenterological Association and the director of the AGA Center for GI Practice Management and Economics.

"An ABN tells the patient it's likely that Medicare won't cover the service and therefore it will be the patient's responsibility to pay if the service is uncovered," Katzoff says. "The patient can then determine whether or not he wants to have the procedure done, given the fact it's likely he will have to pay for it."

These GI Procedures Require ABNs

Some treatments that should not be started without obtaining an ABN include the Stretta procedure and photodynamic therapy (PDT, used to treat esophageal cancer and lung cancer), but Katzoff also recommends obtaining ABNs in any situation in which a diagnostic procedure may not match with the proper diagnosis code.

For example, some Medicare carriers' local medical review policies (LMRPs) accept a diagnosis of diverticulosis for diagnostic colonoscopies (45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]), while others do not.

"If the patient has a diagnosis not listed on your LMRP for the procedure, but the physician still feels that the patient should have the procedure, you should get the patient to sign an ABN" before the gastroenterologist performs the procedure, Katzoff says.

"Also, whenever you schedule a screening procedure, unless you know definitively when the patient last had the procedure done, I'd suggest getting an ABN signed by the patient," Katzoff says.

Suppose your gastroenterologist sees a new patient whose family history puts him at high risk for colorectal cancer. Medicare states that patients at high risk for colorectal cancer are entitled to a screening colonoscopy (G0105, Colorectal cancer screening; colonoscopy on individual at high risk) every two years. If you cannot find documented proof that it has been at least two years since the patient had his last screening colonoscopy, get a signed ABN on file before proceeding.

Medicare's Policy on ABNs

Medicare does not mandate that you use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless the doctor's office has a signed ABN. The ABN proves to Medicare that the patient understands that he might be responsible for the bill, Katzoff says. 

(It may be helpful to have a blank ABN in front of you while reading this section. A copy of Form No. CMS-R-131-G, the general ABN form, is available online at http://www.cms.hhs.gov/medicare/bni/CMSR131G_June2002.pdf).

Be Thorough, Understanding

Explaining to the patient what services you think Medicare will deny and why is the primary function of the ABN, Thomas Bartrum, JD, attorney at Baker, Donelson, Bearman & Caldwell in Nashville, Tenn., said at the American Health Lawyers Association's 2003 Institute on Medicare and Medicaid Payment Issues. Merely writing that Medicare might deem the procedure "medically unnecessary" is not enough documentation for a valid ABN, he said.

In the "Items or Services" box on the form, list all services the gastroenterologist thinks Medicare will deny for the patient. In the "Because" box, list all evidence the doctor provides to support his stance.

Bartrum recommended including anything pertaining to why Medicare may deny the service in the "Because" box. Providing details from Medicare's coverage plans, furnishing examples of similar cases in which Medicare refused payment, and including specific details about the patient's individual claim are some ways you can increase the patient's understanding of the situation.

For example, Medicare covers screening colonoscopies (G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) at a rate of once every 10 years for patients at average risk for colorectal cancer. A gastroenterologist should explain this on an ABN if he feels that the patient needs another screening colonoscopy less than a decade since the last one.

Be as specific as possible when explaining why Medicare might deny the claim, Bartrum said; the patient will certainly appreciate it. Furthermore, it will also help to keep you from drawing the ire of the CMS' Routine Notice Prohibition police.

Duplicate, Duplicate

Be sure each ABN you file is filled out in duplicate; you'll need one copy for your records and one copy for the patient. These forms must be identical. If there is an inconsistency in the similarity of the two documents and the patient complains about it, your office will most likely be the one with the headache, Bartrum said.

Be Proactive

Except under extremely rare circumstances, the gastroenterologist should give the patient the ABN before performing the service. This allows the patient to make an informed choice on the treatment options in a relatively low-stress environment.

"Inform the patients at the time they schedule the appointment that the service may not be covered," says Katzoff. Then, deliver the ABN ASAP.

An ABN is ideally handed to the patient "by the physician, or a nurse, or someone on the clinical staff so they can answer the patient's questions," Katzoff says. But you can also use mail, fax, or online notices when hand delivery is impossible.

Notifying the beneficiary by phone is an option, but certify your call with a mailed form or a personal visit with a form in hand. If you follow up with either of these methods, count the time of the phone call as the delivery time - not the time of the second notice.

Follow CMS Definition of 'Deliver'

Not only must you make sure the patient has a copy of the ABN; CMS doesn't consider an ABN "delivered" unless the patient understands the form and its contents.

No matter what the situation, your office is responsible for making sure the patient understands the ABN. If you would like to start photodynamic therapy (PDT) on a patient who speaks little English, for example, Bartrum said the physician's office is responsible for making sure the patient understands the ABN - even if it means paying to have the letter translated or bringing a translator to act as an intermediary.

In all situations involving an ABN, provide the patient with all the information, medical or otherwise, he requests. The ABN exists to ensure that the patient makes an informed treatment choice, and your office should do everything it can to make sure the patient is informed maximally.