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.

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 whether Medicare will pay for a service or procedure, request that the patient sign an ABN. For example, in the above scenario involving reprogramming of a DBS, the neurosurgeon must ask the patient to agree to an ABN before the reprogramming, not after the claim has been submitted and denied.
 
The neurosurgeon does not need to provide an ABN when providing procedures/services that Medicare never covers. An ABN in these cases is allowed, and the physician may ask the patient to sign to verify that he or she is aware of responsibility for payment.
 
In some cases, the patient may request that the neurosurgeon submit a claim for noncovered services in hopes of receiving coverage from a secondary insurer. Such claims should be submitted with modifier -GX (service not covered by Medicare). Medicare will issue a denial notice, allowing the patient to pursue payment from other insurance.
 
Modifier -GX will be eliminated on Jan. 1, 2002, and will be replaced by two new modifiers: -GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) and -GZ (item or service expected to be denied as not reasonable and necessary).   

Use the -GY modifier when billing a general program exclusion service to Medicare. Use the -GZ modifier when billing a service that doesn't pass medical-necessity edits and a signed ABN was not obtained. Complete instructions for the new modifiers are available at www.hcfa.gov/pubforms/transmit/B0158.pdf.
 
Do not use an ABN to unbundle services bundled by CPT or the national Correct Coding Initiative. Only the more extensive procedure may be billed. Charging the patient for any procedures included in a more extensive procedure is "double-dipping," regardless of whether an ABN is used, and is forbidden by Medicare. For instance, the neurosurgeon may not bill separately for microdissection (69990, use of an operating microscope) if payment is included in the primary procedure.
 
How: Even when Medicare is not expected to cover a service/procedure, the provider must still file a claim with his or her Medicare carrier. If an ABN has been collected, report the service/procedure using the appropriate CPT code and append modifier -GA (waiver of liability statement on file). This alerts Medicare to note on the explanation of benefits that the patient is responsible for payment.
 
Medicare updated and standardized its ABN form effective July 1, 2001 (CMS memorandum A-01-77, change request 1192, dated June 27, 2001). The ABN is a simple form that may be reproduced on the individual provider's letterhead. A sample ABN (OMB Approval #0938-0566, form #HCFA-R-131-G) and instructions on its completion may be found on the CMS Web site, www.hcfa.gov/pubforms/transmit/B0130.pd. Click the link below the heading "April 19, 2001-Information Collection Requirements in HCFA-R-131." The memo number B-01-30.
 
In all cases, be sure to give the patient a copy of the signed ABN for his or her records.

Medicare defines "incident to" services as services provided by a nonphysician practitioner (NPP) that are an integral part of the physician's personal professional services in the course of a diagnosis or treatment of an injury or illness, says Ron Nelson, PA-C, reimbursement policy analyst, president of Health Services Associates Inc., a family practice in Fremont, Mich., and past president of the American Academy of Physician Assistants. Services provided incident to are reported with  the appropriate CPT codes under the supervising physician's personal identification number (PIN) and are reimbursed at 100 percent of the Physician Fee Schedule.
 
Note: Incident to services are distinct from those provided by an NPP using his or her own PIN, which follow different guidelines and are generally reimbursed at 85 percent of the Physician Fee Schedule rate.
 
Section 2050 of the Medicare Carriers Manual (MCM) outlines the four main guidelines for billing incident to. The NPP providing incident to services does not need to be licensed under state law as long as four criteria are met:
 
1. The physician must be involved: The neuro-surgeon must see all patients to establish diagnoses and/or a treatment plan. Although the NPP may provide subsequent services as determined by the physician, he or she may not provide initial care, Nelson warns. Nor may the NPP see patients on his or her own. The neurosurgeon must always be involved in patient care, and any services or procedures billed incident to must be those typically provided under the physician's PIN.
 
2. The NPP must be under the physician's "direct supervision": This second requirement relates to the first and specifies that coverage of services incident to the physician's services "is limited to situations where there is direct personal physician supervision," according to the MCM. As defined by the MCM and reaffirmed by CMS Program Memorandum No. B-01-28 (April 19, 2001), "Direct supervision does not mean that the physician must be present in the same room with the NPP, but he or she must be present in the office suite and immediately available (in person, not via telephone) to provide assistance and direction."

3. Incident to services must be provided in the physician office, institutional office setting or patient's home: Incident to services may never be billed in the hospital. For instance, if the NPP assists the neurosurgeon in making hospital rounds, his or her services may not be billed incident to.
 
Note: An institutional office setting is a location leased by the physician within another institution (e.g., a nursing home or rehabilitation center) as a temporary office space. 
 
4. The NPP must by employed by the physician or by the physician's employer: According to the MCM, to bill incident to, the NPP performing the service must be a "part-time, full-time or leased employee of the supervising physician, group practice or legal entity that employs the physician who provides direct personal supervision." Services provided by NPPs not employed by the physician or group practice may not be billed incident to, even if the services are based on a physician's orders, Nelson says.
 
To demonstrate that these four requirements are met, documentation supporting the incident to services must link the NPP to the supervising physician. This could include the physician's signature on all notes or charts provided by the NPP, notation from the supervising doctor proving that he or she saw the patient initially to establish diagnoses or treatment plans, and documentation from additional dates of service (other than those requested) showing the physician's involvement in the patient's care. Always document the supervising physician's presence in the office suite.
 
For instance, pain-pump maintenance, such as filling and port flushing, is often performed by a nurse under incident to guidelines. For this minor service, the nurse reports 99211 (office or other outpatient visit for the evaluation and management of an established patient) and documents the date of service, vital signs (if taken), the service provided and his or her signature. The nurse should also note the surgeon's presence in the office suite.