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 [...]