Ob-Gyn Coding Alert

Question: What is the correct sequence of coding for a pessary insertion for a Medicare patient? Does a waiver need to be signed?

Pat McDermott, Office Manager, Drs. Gambett and Henry, St. Helena, CA

Answer: When inserting a pessary for a Medicare patient, you need to keep several things in mind. First, reimbursement for the pessary supply may lag behind costs. Currently, Medicare is only paying around $12-$24 for the pessary, while the cost to the physician could be as high as $45-60. In order to obtain Medicare reimbursement, you need to supply the pessary. You cannot write a prescription for the pessary and have the patient bring it in, because the patient would have no way to recover even a small part of her cost. This would be like denying her a Medicare benefit. So, the options are to provide the service and code and bill for the service even if it means a loss, find a less expensive source for the pessary to minimize your loss, or stop providing the service. A waiver is only needed when you believe that a covered item may not be covered under the circumstance you are billing; that is, the normally covered service is not medically necessary for the specific claim submitted. It would be very unlikely that Medicare would deny the insertion of a pessary because it is not medically necessary so a waiver would not be appropriate to obtain in this instance. Since the pessary is a covered benefit, you would either accept Medicare payment, if you are participating, or you would be subject to the 115% limiting charge for balance billing if you are not.

The right Medicare billing sequence is to bill the 57160 to Part B for the insertion and bill the A4560 to the DMERC using your supplier number. Keep in mind, if a significant and separately identifiable E/M service is also provided on the day of the pessary insertion, you can also code for that service at the appropriate level by adding a modifier -25 (significant, separately identifiable E/M service by the same physician on the same day).