Neurosurgery Coding Alert

The Office of Inspector General (OIG) has released its work plan for fiscal year 2002, outlining areas of federal healthcare spending, i.e., Medicare and Medicaid expenditures, that will receive special attention during the next year. Among the goals of the program are isolating instances of fraud and misconduct, "reducing hospital payment errors" and  "evaluating the efficiency of controls over Medicare payments for medical education."
 
Areas targeted for special scrutiny include E/M coding, procedure coding of outpatient and physician services (outpatient services billed by a hospital and a physician for the same service) and consults. And for the second year in a row advance beneficiary notices (ABNs) and "incident to" billing (services/supplies billed by the physician but provided by allied health professionals, such as nurses, technicians and therapists) will be the focus of increased OIG attention. The continued investigation of ABNs and incident to billing serves as notice that physicians consistently have difficulty in these areas. By following a few basic requirements, neurosurgeons can avoid such common billing mistakes.
The "What," "Why," "When" and "How" of ABNs
What: An ABN is a written notice provided by the physician to inform a Medicare beneficiary that a particular service or procedure may not be covered by Medicare and to ask the patient to pay, says Joseph R. Batte, CFE, former supervisory special agent for the OIG and an independent compliance consultant. Or, the patient may indicate on the ABN that he or she elects to forego the recommended but noncovered service/procedure. The ABN must clearly identify the service/procedure to be rendered and state why it may not be covered. The ABN affects only those services/procedures specifically listed. The physician may not use a "blanket," or nonspecific, ABN, and payment may only be collected if Medicare denies reimbursement.
 
Used properly, an ABN protects a practice's bottom line by ensuring payment for services not covered by Medicare. Used incorrectly, an ABN can lead to unpaid claims, difficulties during an audit or even allegations of abuse.
 
Why: According to the OIG, physicians "must provide ABNs before they render services that they know Medicare does not consider medically necessary or will not reimburse." For instance, a patient's diagnosis may not warrant a procedure per Medicare guidelines, or the physician provides legitimate services that exceed frequency parameters.
 
For example, most carriers will pay for reprogramming of implanted deep-brain stimulators (DBS) (95970-95973) only once every 30 days. If the neurosurgeon provides this service more frequently due to adverse patient reactions, an ABN would be necessary.
 
When: The proper time to have the patient sign an ABN is before providing the service or procedure, Batte says. In some cases, the neurosurgeon may not know if a service will be covered. When in doubt about [...]