Neurology & Pain Management Coding Alert

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

When your neurologist 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 have exceeded Medicare's frequency guidelines and procedures that Medicare doesn't ever reimburse.

Over-the-limit procedures: Medicare only allows for a finite number of certain procedures per patient per time period. Nerve conduction studies (NCS) are a prime example of this for neurology practices. You report NCS with the appropriate choice from 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), 95903 (- motor, with F-wave study) or 95904 (- sensory). CPT's Appendix J -- and your local Medicare carrier's guidelines -- will help you keep within the allowed boundaries for NCS.

Never-reimbursed procedures: Also, there are some procedures that Medicare doesn't ever cover, such as administering Botox for sialorrhea (527.7), says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center in Shadyside. In these cases, you won't need a signed notification unless a secondary insurer is willing to pay for the service.

Why Try an ABN?

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

• to ensure reimbursement for services provided but deemed not covered by Medicare, and
• to reduce the risk of compliance implications associated with ABNs.

When you present patients with an ABN (and explain it to them), you help patients decide whether they want to proceed with a service even though they might have to pay for it. A signed ABN ensures that your neurologist 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 approved by Medicare 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 cumulative trauma disorder. Mrs. Smith had an electromyography (EMG), but her physician sends her to your neurologist for a second opinion and more in-depth study before making any treatment decisions. Your neurologist provides a full workup, including another EMG, 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 EMG 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.

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 a patient or for consultation or medical management or for coordinating medical management with other health-care professionals [e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists] ...).

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.