Ophthalmology and Optometry Coding Alert

Presented by Stacie L. Buck, RHA, LHRM

The following supplement to Radiology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Stacie L. Buck, RHIA, LHRM, is the president of Health Information Management Associates, Inc. in North Palm Beach, Florida. She has served as a medical records coordinator, medical coder, revenue analyst, internal auditor, corporate compliance officer and independent consultant during her 13-year career in health information management. Stacie frequently writes and speaks on coding and compliance topics and has authored several training handbooks including the Medical Necessity Training Handbook for Physicians and the ABN Training Handbook for Physician Practices. Stacie is an adjunct instructor and advisory board member for the health information management program at Indian River Community College in Florida and currently serves on the Board of Directors for the Florida Health Information Management Association.

Thank you Mandy.  It is pleasure to be here this morning to speak to everyone about ABNs.  This morning, I am going to take a little different approach to doing an audio seminar on ABNs, I know a lot of times when this topic is presented, it really focuses on obtaining the ABN itself.  I want to do today is not only go over obtaining a valid ABN, but also give you some information at a higher level and also help you implement processes and policies and procedures in your facilities.  So some of the things that we are going to cover today are compliance, implications associated with ABN, of course we will also talk about making medical necessity determinations, obtaining valid ABNs, billing with the appropriate modifiers and condition codes - which is crucial to your billing process.  Also we will take a brief look at how you can get the content of NCDs and LCDs modified.  We will also take a look at implementing policies and procedures and we will go over some process recommendations for you to use in your facility or your practice.

It always amazes me that as long as ABNs and medical necessity has been around, it is such a challenging issue whether you work in a hospital setting or in the physician setting.  So hopefully today with what I am giving you, this will actually help you kind of hone in on some of those areas that you may find as a weakness and help you actually turn things around and collect money by getting ABNs. 

One of the first things I want to discuss is the Medicare financial liability provisions, just briefly..  Basically the liability provisions protect the beneficiaries and providers under certain circumstances from unexpected liability, for charges associated with claims that Medicare does not pay.  There are actually two types of Medicare financial liability provisions, which are listed for you on this first slide. There is limitation on liability and there are also the refund requirements. Now the limitation on liability, this applies to those providers who participate with Medicare and the refund requirements applies to those providers who are not participating with Medicare. And as we all know, Medicare usually relies on that primary diagnosis code to make that medical necessity determination.

Now on the next slide covered versus non-covered services, I want to briefly to go over this terminology, because I find that anytime a service is denied from Medicare, people always say, 'oh it is non-covered; they denied it because it was non-covered.'  Well, it really is not a correct use of the term because you have non-covered services, which are never covered by a third party payer regardless of the diagnosis or circumstance for that particular patient.  These of course are the statutorily excluded services that Medicare documents in the social security act.  Also, it is important to note that other third-party payers obviously make their own determination as far as what it is non-covered.  So for other payers that you deal with, the Medicare coverage requirements and the requirements, as we all know, can differ greatly. 

For covered services, these can be either preventive or diagnostic because now we know that Medicare does cover several different preventive services and the covered services can be either medically necessary or not medically necessary, so this is where we get into where when you get a denial, you say, 'oh, it is non-covered by Medicare.'  Well, the service was covered.  It should say in this particular instance, Medicare denied it for medical necessity.  What we do to determine whether or not the service is covered, or whether or not it is medically necessary, is we look at the Medicare covered decisions and Medicare has national coverage decisions and they also have what they now call the local coverage decisions which are formally called LMRPs.  This is what we used to determine medical necessity.  So moving along, we will talk about this in a little bit more depth in few minutes. 

The beneficiary notice initiative: this is something that CMS put together to, as it states here on the slide, wed consumer rights and protections with effective beneficiary communication, so that beneficiaries have the opportunity to timely exercise the rights and protections in a well-informed manner.  Basically what this whole beneficiary notice initiative does is it provides a means for Medicare beneficiaries to be notified in advance of those services that Medicare may not pay for, so that is really the whole history behind the ABN and the medical necessity with this initiative that CMS had put forth. What it does is it allows the beneficiary to make a decision as to whether or not they would like to receive that service.  The advanced beneficiary notice itself is on the next slide.  I have here that CMS has published two official ABNs.  There are, in actuality, several different ABNs out there, but the two that would be pertinent to physician practices and services provided in the outpatient arena in the hospital are listed here: that is the CMS-R-131 G and this is the general ABN, which can be used for any services including lab services.  We also have the CMS-R-131-L and this is used only for lab services, so this is something that was developed specifically for labs. These are the approved forms that CMS requires providers to use and in your packet today copies have been provided for you of both of these forms, as well as another form that I will mention a little bit later in the presentation, so you have those to refer to.

On the next slide, why it is so important that we get these ABNs, this whole issue does not seem to go away.  There are two main reasons why you want to get an ABN.  The first is to increase your revenue and the second is to reduce your risk or the compliance implications associated with ABNs.  I am going to talk a little bit more in depth about these over the next couple of slides.  On the next slide, you will see, we want to increase our revenue, that is why ABNs are important. And if you are in a large facility, if you are in hospital, losses can run hundred of thousands to millions each year.  If you are in a physician practice, or let say in independent imaging center, you may not generate quite as much revenue as a hospital would, but if you take a look at the amount of money that are going losing versus what you could potentially be collecting.  Even though it may only be $30-$50,000 a year to you, when you compare that to your revenue, it could have a significant impact on what you are doing. So, what you want to do is you want to implement front-end checks and use the ABN, it is very important that you do this.  Throughout the presentation today, we will talk about how you can implement an effective process.  What is nice about having an ABN signed and on file, is that providers can actually bill the patient for the full charge when an ABN is signed and I have a little example here on the slide, how this could potentially effect your revenue stream.  These are numbers that I pulled out of the air, I do not know the accuracy of them, they may be close to what your fees are and what the reimbursement is from your Medicare carrier, depending upon where you are located, but this is not for any particular area.  The example I have here, If you are performing a CT of the pelvis and let us say your facility charges $750 for this particular procedure, Medicare has allowable $400, so for this procedure, you are receiving 40 denials per month.  If you are not getting an ABN signed by the patient, what you are doing is you are losing $208,000 per year by not getting an ABN signed by the patient.  Now in scenario B, if you have the signed ABN, you have a potential - and I use the word potential here - potential gain of $360,000 per year.  The reason being is that when that ABN signed, you are then able to bill the patient for the entire charge; whether or not you correct the entire charge is a completely separate issue, but you are well with in your rights to bill the patient that entire charge and try to collect that from the patient.  What I do see with a lot of providers though, is that they will actually extend a discount to patients in these scenarios and typically what I recommend to my clients is if you are going to do that, I would discount it down to the Medicare allowable rate.  I think that is fair and some people have adopted a policy to automatically do that, rather than billing the patient the full charge, they will automatically discount it and then they will send the bill to the patient for the Medicare allowed amount.  My opinion on that is that you really should bill the patient the full charge the first time around, because there are some patients that will indeed pay you the full charge.  I see it happen - there are people who get their medical bills, see them and pay them in full.  I know that they are probably in the minority, but they are out there.  So I usually advise practices not to do that immediately, not to take discount off the top because of the fact that you may have patients who will pay it.  Also, if you have patients who get the bill and call you and say, 'I really cannot pay this,' then on the back end, you can say, 'okay, Mr. Smith, I can give you this discount, we'll mark this down to say $400, and then Ms. Smith is very happy because he feels that you are doing them a favor, so it is a PR thing to.  In a way, it looks like you are actually working with them and trying to help them.  Then of course you are still going to have the patients who are upset and irate and who will not pay for anything because they say Medicare pays for everything, which we all know is not true.  But there is still that mindset out there among patients.  So, you really just have to work with patients on a case by case basis. So that is my two cents on how you should bill those, but take it for it for what it is worth and do whatever works best for your patient population.

On the next slide we are talking about why we need ABNs.  We want to reduce our compliance risk.  Some of the issues we need to be concerned with are cost report violations, and what some facilities, some providers will do is they will actually omit charges on the back end and write them off as bad debt, but medical necessity denials are not considered as bad debt for Medicare cost reporting purposes, so that is one issue.  There is also a mandatory claims submission provision where you should be submitting all of your claims to Medicare.  The question is always asked well, cannot we get in trouble for submitting claims to Medicare when we know that is going to be denied, and when we know that they are not going to pay?  This is where the use of modifiers comes in to billing your claims, which we are going to talk about a little bit more towards the end of presentation.  By using these modifiers appropriately then you will cover your bases because you will be letting Medicare know that we expect that this is a denial, but we are submitting it to you anyway for denial and we will see that a little bit later on. 

You also have the risk of fraud and abuse charges.  There are Stark and anti-kickback implications here, and what Medicare may say is that if you are not getting ABNs and you are routinely writing off these charges that are denied, then in essence what you are doing is you are providing free care to the beneficiaries and this can be construed in two different ways.  First, if the patient knows that they are never going to pay anything when they come to you, they will continue to come to you for services.  The second is, if the referring doctors feel that every time they are sending the patients to you, the patients are not paying anything and they are getting free care and that is inducing referrals, that becomes an issue. So it is on the patient side and also the physician side and of course providers can pay sanctions for any of these charges. 

One important thing to note for those of you who are working the hospital side of things and if you are being paid under the OPPS, you need to report everything on your Medicare claims.  Even those things that do not have separate reimbursement and what not, because what Medicare does is they look at the resources that are used for the services which you are providing and then that helps them assign the future reimbursement to that APC for a particular procedure or particular service.  So you are going to report all of these things line item by line item for that reason because without you reporting that, they really do not have any data to go back and basically change the reimbursement in the future.  There are some procedures where maybe they would actually increase reimbursement when they see that there are several resources being used for that procedure.  That is on the outpatient hospital side.

On the next slide, we have NCDs and LCDs. The NCDs, of course, are your national coverage determination, which are nationwide policy statements that apply to all providers that submit Medicare claims. NCDs take precedence over LCDs, which are your local coverage determination.  The local coverage determinations are, of course, issued by all of the individual Medicare carriers and LCDs specify the indication and limitation on coverage for that particular Medicare carrier.  The Medicare carriers that come up with the LCDs, they need to ensure that they are consistent with national instructions and LCDs may not conflict with NCDs.  Usually what happens if you have an NCD and LCD in the same area, the LCD may act as a supplement to the NCD itself, possibly imposing frequency limitations on certain services or maybe supplementing the code list, as I have mentioned here, when the narrative indicates subgroups of a broad code.  But generally speaking, probably what most of you refer to more often than not, would be your LCDs, your local coverage determinations, which are those policies where Medicare carriers have the list of covered or non-covered ICD-9 codes, depending upon how they are listed in the LCD.  And obviously that is what you will use to make your medical necessity determination.

Now on the next slide: performing a medical necessity check.  These are some basic steps that you will take in order to determine whether or not you will obtain an ABN.  First when the patient presents with a prescription, you want to look at that and determine whether or not that test or that service has an NCD or an LCD.  If there are no limitations on coverage, then you would proceed with the test and the patient would not sign an ABN.  If you do fine that the test or service has limited coverage, whether it be under an NCD or LCD, you are going to review the signs or symptoms or diagnosis that prompted the test to be ordered and see whether or not it is a covered indication under that policy.  If you find that it does not meet the medical necessity requirements and the signs and symptoms or the diagnosis is not on the list, then you are going to have the patient complete an ABN and we will look at that in a moment - how to complete the ABN. 

You also have another common reason that you are going to look at: for tests with frequency limitations,  you want to review the appropriate section of the LCD and make sure that you obtain an ABN if the patient actually is exceeding frequency limitations.  One example of that would be a screening mammogram, those are allowed once per year with Medicare coverage.

On the next slide, obtaining a valid ABN.  Providers are expected to obtain ABNs under the following circumstances. 

Coverage for services or items may be allowed only for specific diagnosis or conditions.  These are ones that are outlined in your LCDs and NCDs. 

Coverage for an item or service may be allowed only when documentation supports medical need.  What you will find for a lot of your services that you provide if you go through and look at the LCDs and NCDs, is that Medicare has actually spelled out specific documentation requirements that have to be met for particular tests or services.  So what will happen is if they ever did a post-payment review, they would expect to see the information on file and then if not, they could actually ask for the money back.  They would consider it an overpayment.  So that is something to keep in mind.  One example of the service that has very specific guidelines would be PET scan.  The type of PET scan that you are having done determines the documentation that is required to be in the patient's chart prior to the scan being rendered. 

The next one here on the slide, coverage for an item or service may be allowed only when frequency is within acceptable standards and this is one that I had just mentioned on the last slide, so we need to take note of our frequency limitations.
 
Continuing on the next slide with obtaining a valid ABN, you should not get an ABN when Medicare is expected to pay, when the provider never knows whether or not Medicare will pay, and when an item or service is not a Medicare benefit.  So basically, in order to obtain an ABN, you have to have a reason to believe that Medicare will not pay for the test or service, and what this one means here, 'item or services not a Medicare benefit' - if it is a statutorily non-covered service, those services outlined in the social security act, the routine physicals and immuno-screening tests and so on and so forth, then you do not need to get an ABN.  Now I have had some people ask, 'if a patient comes to me and it is a non-covered service, can I give them an ABN?' Yes absolutely you can give them an ABN as just kind of a service or reminder to them if you choose to do so.  However there is another form that you may want to consider using which is in your packet and that is the notice of exclusions from the Medicare benefit, the NEMB and that actually shows all of those non-covered services.  If you want to get more specific with your patients, you could do that, certainly it is not a problem doing that, but you do not have to get an ABN for statutorily non-covered services.

On the next slide, some additional guidelines for obtaining a valid ABN.  It has to be given prior to a service being rendered - that is key for the ABN, that is whole point of the advance notice.  It has to be on one of the approved CMS forms and CMS came out with these, I believe, back in 2002, and use of these forms was mandatory by January 1, 2003, if I remember the dates correctly.  So hopefully you have seen these forms and you have been using these forms.  If you have not have been using these are forms, you should use them going forward. 

Notification may be done via telephone.  Sometimes those initial decisions will be made over the phone.  The initial contact will be to the patient over the phone, but you want to follow up with the signed form.  It is very important for that follow-up.  Last moment delivery of an ABN is prohibited, and this is actually after treatment or procedure has been initiated.  So if you have taken the patient in the room somewhere and you have administered anesthesia, you have already administered contrast, at that point, it is too late to give the patient the ABN because they could feel pressure at that point to sign it because the service has already started.  So it has to be done prior to the service starting for that patient.  You want to make sure that you have duplicate ABNs, one copy should go to the beneficiary and then one should also be kept for the billing office to use in case of appeals or what not, or if there are any questions as to whether or not an ABN was signed.  Also the billing office needs to know whether or not an ABN was signed, so they can add the appropriate modifiers to the procedures or services that were rendered and it is also important that the beneficiary is able to comprehend the instructions.  That is one of the reasons why CMS came up with the standard form, it is to make it uniform so that all of the beneficiaries were receiving the same information, the same guidance and that it was written at a level that they could understand.

On the next slide, obtaining a valid ABN.  I want to talk a little bit about repetitive services.  This is a question that comes up.  When you are performing repetitive services, a single ABN may cover an extended course of treatment when the ABN identifies all the items and services that Medicare will not pay, so this would apply to patients who are coming in for those recurring services when you are billing out claims on a monthly basis, so this would apply to you if work on the hospital side and you have a lot these recurring accounts. 

Standing orders, you have to list the frequency and duration on the ABN and there is a one year limit, so if the patient has standing orders and the treatment time limit goes beyond the year, what happens after a year, a new ABN has to be signed.  So, for standing orders it has to be signed at least once a year.  If there is a change in the frequency and duration, I would recommend getting a new ABN signed anytime there is an actual change, so there won't be any issues or any question as to what the patient will be responsible for.  If additional items or services for which Medicare will not pay are needed during the course of treatment, a separate ABN must be issued.  So this is where they are going through these repetitive services, but maybe during this time, the doctor orders an additional service, then of course you would want to get a separate ABN for this test or services that the beneficiary is getting at that time.

On the next slide, completing ABNs, I have listed the information required on the ABN and if you want, you can actually take a look at the ABN forms in your packet, those are towards the end.  There is the general form that I mentioned earlier and also the lab form.  You will see on the form that it requires the patient's name and the Medicare number, the service that Medicare will likely deny written in the appropriate box , depending on which ABN you are using.  You are also going to write the reason that you anticipate the denial in there that would be your 'because' box.  You will see on the lab form, it already has the reasons for you; 'Medicare does not pay for these tests for your condition; Medicare does not pay for these tests as often as this, denied as too frequent; and Medicare does not pay for experimental or research used tests.  So, for talking about lab work, they already have the reasons here, you are just actually filling in the test under the appropriate reason.  On the general form, which is used for the other services, you actually have to write out the items or services and then all also fill in the reasons on there.  There is also a place that says 'estimated cost' for you to write the estimated cost of the service.  Not including a price on your ABN does not invalidate the ABN.  I know that there has been debate over this, but if you actually go out and look at the instructions on the CMS Web site, in the Medicare claims processing manual, it clearly states there that you do not need to have the estimated cost, it is not required, it would not invalidate your ABN.  Beneficiaries, once this form is completed, they need to check one of the boxes on the form.  They either are going to check yes, they want to receive the items or the services, they are basically going to sign it that they know that they are responsible for payment if Medicare denies, or they are going to take the second option which is that they have decided not to receive the services at this time.  Then providers must date the form and then beneficiaries or the person acting on the patient's behalf will sign the ABN form, so that is essentially what you are doing with the form. 

So those are your two most common reasons and what you may want to do with your ABN form is come up with some standard reasons for denial, and these are two that you can use, and customize your ABN forms.  By taking this information and actually putting it on an ABN form and simply checking it off, we will ensure consistent language, regardless of who is actually having the patient sign the ABN form, so it is also a consistency issue.  That is something you may want to take a look at and we will talk about customization a little bit later as well.

Moving on to the next slide, prohibited ABN use.  CMS says that giving generic ABNs and blanket ABNs is not allowed and basically with this refers to is when you are giving patients ABN and you are not stating a specific reason as to why Medicare will not pay for the test, or if you are giving an ABN to all Medicare patients regardless of what they are having done.  I have actually seen this -providers, and it goes one of two ways.  It is either too much trouble to get an ABN, so I am just going to ignore them altogether, which is a compliance risk itself.  On the other side, I am just going to give ABNs to all my Medicare patients to cover my bases and collect my money - that is also a compliance issue. And I have actually gone in and done assignments where providers are doing this and I tell them you need to stop that immediately, because basically those ABNs are worthless.  At that point in time, they are going through the motions, but it is not going to benefit them.  Also, I have seen in charts that I have reviewed, a blank ABN with the patient's signature on it.  Let us say Medicare came in and did an audit and found that that, it would be a serious issue because what is happening is, you are obtaining the patient's signature on a blank form, they have not been informed and somebody actually has the ability to go in and fill in that form after the fact, so that is a no no.  So, if that is happening in any of your facilities or your practices, that means to stop.  I know that we get into the habit of when the patient is filling out their paperwork when they come in the front door, we just highlight and put a little x where they need to place their signature on everything and some people do that with the ABN, just in case they need it. 

Once again, it defeats the purpose of the ABN, which is a notifying the beneficiary in advance that Medicare may not pay for the service. 

Some exceptions to these rules: if you have services that you know are always denied for medical necessity, you can routinely get it for those particular tests or services.  If items or services are experimental, these are usually non-FDA approved procedures or services, and frequency limitations.  A lot of times when you have these tests with frequency limitations, if the patient has been going elsewhere for treatment or elsewhere for tests, you may not be able to determine when the patient last had a service.  So in this particular case, let us say for a mammography or maybe even your DEXAs that are done for bone density.  If those are two tests that you work with, because those have frequency limitations on them, it would be okay to actually get that ABN signed for all of those.  If it is one of your patients and you can make the determination when the last time the patient had it, then have them sign it; but if they could have gone elsewhere and had the service, you will not know and what will happen is that you will get denied on frequency because the patient had the service somewhere else.  So Medicare does allow you to get the ABNs when frequency limitations are in place.

Now on the next slide, what happens if the patient refuses to sign the ABN - and this happens, patients do refuse to sign.  Two witnesses must sign the ABN form, attesting that the patient refused to sign, but demanded the service.  So what will happen if the patient is going to refuse to sign the ABN and then person who was trying to get the ABN signed will basically write a note saying, 'the patient refused to sign,' sign and date it, and then they are going to find somebody else to witness the patient refusal.  At that point, this goes back to the financial liability provision I spoke about in the beginning this morning.  You have to fill your obligation in notifying the beneficiary that Medicare may not cover the service, so you need to fulfill your obligation under the limitation and liability.  The patient goes ahead and has the test, once you perform that test, you could then bill the patient for that test, because you have fulfilled your duty.  What you are going to do is bill that service with that GA modifier just like you would for all of your other services where an ABN was signed.  Like I said, we are going to talk about the modifiers and the billing a little bit later on.  But that is something that has been in place for a very long time, but a lot of providers still are not aware of it or do not know exactly how to handle it.  So once again, you can bill the patient if you have two witnesses sign that form. 

Now ABNs and EMTALA, for those who work on hospital side.  This is always a hot topic as well because as we all know ,the ED is place where we lose a lot of money for medical necessity denials, because the doctor essentially is ruling out many different conditions.  So, in the ED, what can you do?  In the ED, you can get an ABN, however you need to make sure that all EMTALA requirements are met prior to giving a patient and ABN.  And there is one thing I want you to add to the slide, a third bullet point that I missed.  I have the first one: an MSE must be complete before obtaining an ABN and you screened for medical necessity on all exams ordered after the MSE is complete.  Actually, you need to complete the MSE and the patient has to be stabilized, so please write that on the slide.  MSE has to be completed and the patient has to be stabilized.  Once those two things are done, moving forward, any tests ordered from that point forward, you can approach the patient with an ABN form and ask them to sign that ABN form.  Unfortunately, anything up to that point, if it is denied, there is not really much you can do about it.  Obviously you can always appeal those because it is an emergent situation and Medicare may or may not give consideration for payment.  But it is key to know that you can do it, but you need to make sure the screening exam has been done and the patient is stabilized before moving forward.  So the same rule is going to apply to ABNs as getting financial information from the patient in the ED - same thing. Obviously if they need to be seen, you are going to take them back and do the exam and stabilize them before you discuss anything financial with the patient, but it can be done.  It is a little bit more difficult to implement a process in the ED, but if you have somebody back there who is already going in and talking with the patient, gathering the information, things of that nature, then this is just another step that you can add to that process.

Now in the next slide, I want to talk a little bit about documentation because documentation is so crucial as medical necessity.  I mean obviously that is what Medicare is going to look at whenever there is a question about a claim that has been billed or when you are appealing a claim, it all comes down in documentation.  Your documentation supporting medical necessity can be found in many different places in the patient record.  It may be found in history and physical, it may be found in progress notes or your office notes, your tests orders - the test orders are usually what is used to make the initial medical necessity determination, test results with written interpretation and radiology reports.  The reason why documentation is so important, and I alluded to this earlier, is that you have certain NCDs and LCDs that specifically lay out documentation guidelines that have to be met for different services.  So you will want to become familiar with the NCDs and LCDs for all the services that you provide, go through them all, see if there are specific documentation requirements for those tests, and then make sure that you are adhering to hose.  Another place that you may want to look is the Medicare claims processing manual and also their benefits coverage manual to see if you can glean additional information from those two sources, which are out on the CMS Web site. 

So that brings us to the next slide, identify all applicable policies for the services you provide. What you want to do is, I would recommend doing like a spot check when you identify those, do a small retrospective audit.  Go back and see if you have the appropriate information documented in your medical record, and if not, then implement a process going forward. Have someone actually do a review, making sure that you have all that information in the medical record before performing the test or service, and you may want to do that by developing a checklist that is actually completed before the patient comes in for the service.  If deficiencies are noted, you want to develop templates for required documentation, which also ties in with your checklist.
 
Now the other important thing we have to talk about are the coding guidelines, because it is the primary diagnosis code that drives the medical necessity determination the majority of the time.  So just to review the general coding guidelines here for our outpatient services.  We want to use the ICD-9 code that describes the patient diagnosis, symptoms, complaint, condition or problem.  We do not want to code a suspected diagnosis.  We can do this on the inpatient side, but we do not do it on the outpatient side.  I know that we still have physicians who continually right 'rule out rule, rule out.'  It is okay if they want to write "rule out" with a  specified condition, but they need to give us the signs and symptoms and what I find is that when I am doing audits and I am working claims on the back end, let us say after there has been a denial.  I go to the chart and the doctor wrote 'rule out' and then the exam was normal and so essentially what happens if the provider does not get paid.  What I say to them is, let us go back to the referring physician, what is requested from his office notes, and let us see what we could find, and I would say a good 70-80% of the time, the indications that would support medical necessity are documented in the referring physician's office notes, they just did not make it onto the prescription.  So that is why it is sometimes important to go back and dig and get a little bit more information from your doctors, but I know the rule out is still an issue, even after all this time.  Of course, we want to use the ICD-9 code that is chiefly responsible for the item or service provided.  We are going assign our codes to the highest level of specificity and you are only going to code chronic conditions when they apply to the patient's treatment and if they affect the treatment at that particular visit.  We are not going to code conditions that no longer exist. 

Now as far as making the determination of the primary ICD-9 code, the next slide outlines some steps for that.  If you have a diagnosis confirmed by test results, that is what you are going to code.  This follows the principle of coding to the highest level of certainty, so if you have a written interpretation from a physician for a test or service, you will actually code that as your primary diagnosis code and that you will actually use to do a medical necessity check on the back end before the claim goes out. 

So, essentially what is happening in this whole process is up front, obviously you are working off of the signs and symptoms that the referring physician gives to you, and you are going to use that to determine whether or not you get an ABN from the patient.  So what happens on the back end some times, you have something better to work with.  You have a diagnosis that is a higher degree of certainty that you use and then in that case, the test will actually be paid by Medicare.  So what the patient needs to understand up front is because they are signing that form, you are not saying that they are absolutely 100% going to be responsible.  It should say there is a possibility that they are going to be responsible, so you are not only doing a verification and check on the front end, you are also looking on the back end as well.
 
In the event that you have a test or the results are normal or when the findings are uncertain, if the doctor is documenting probable, questionable, suspected; you are going to code the signs and symptoms that prompted the ordering of the test.
 
So this is where the ABN really becomes key in having that check in place before you have the test, because what happens when the patient has the test and it is a normal test result,  Medicare is going to look at the sign and symptoms.  Of course, we are not going to code any incidental findings or unrelated coexisting conditions.  You do not want to use incidental findings to support medical necessity.  I have seen some people get a little bit creative with their coding.  If something is incidental, if it really is not related to why they were doing the exam, then you are not going to code it.  Chances are incidentals would not support medical necessity anyway, but it could be that coding the incidental diagnosis may -some of these polices are a little bit complex. 

For screening test, of course, these are the ones are performed when the patient does not have any signs or symptoms.  You are going to assign the appropriate V code, and this will hold true even if there is a positive result or if there are findings on that screening test.  A screening is a screening, period, end of story.  So even if the doctor finds something, you are still going to use the V code as your primary diagnosis and then you will code the findings as a secondary diagnosis behind that.  That is very important to remember: if it is ordered as a screening, it will stay a screening, so that is something very important to point out, because I know people have been taking the findings of screenings and putting those first, and that is incorrect. 

Now billing for medical necessity denials, we talked a little bit about this earlier, about billing for the full charge for the test.  But, in this particular case, we are talking about medical necessity.  You do not have the option to collect money from the beneficiary up front when the patient signs the ABN.  You are actually going to get a denial from Medicare and then you are going to bill the patient at that time.  This is different from services that we know that are non-covered.  You can collect on non-covered services from a Medicare beneficiary. 

Now as far as billing claims for services where you have an ABN signed or maybe you failed to have an ABN signed, there are different requirements as to whether or not you are billing on a UB-92 or the CMS 1500 form.  On this slide here, I am going to outline for you what is valid on each and if we flip over to the next page, page 14 of your handout, you will see that I actually start to breakdown some of this information for you for the UB-92 and the CMS-1500.  Now the condition code 20 facilities bill claims with this condition code at a beneficiary's request and this is when the provider has already advised the beneficiary that Medicare is not likely to cover the particular service.  Facilities in this instance may submit the claim with both covered and non-covered charges, and typically this condition code is used when you have a home health ABN form that is signed and payment will be made under HH PPS; or when a hospital or skilled nursing facility knows a non-covered service has been provided.  So this is referring back to some other ABNs.  But I am assuming everybody here for the most part is working in a physician practice or working on the outpatient service side in the hospital. 

For condition code 20, this condition will not be used if the patient has signed ABN form, the R131.  That is something you are not going to use when that signs, so that applies to the other forms.  Condition code 21, this will be used when submitting Medicare claims to receive a formal denial for supplemental billing purposes.  This designates that all services on the claim are non-covered services and that the claim is only being filed in order to obtain a denial for Medicare, so then the secondary payer can be billed.  This code will not be used if the patient has signed an ABN. 

Now occurrence code 32, this basically states an ABN was given to the Medicare
beneficiary on a specified date and this is used if you have obtained an ABN form and these are the ABN that we talked about today and are in your packet.  You only want to list service for which an ABN was given on one claim and on that claim you are going to put condition code 32, so you are going to have one claim with all of the service that got an ABN for using condition code 32.  Also only include cover charges on the claim form when using this code.  So once again, this goes back to non-covered, covered definition for you to understand that.  You are not going to use condition code 20 and 21 with occurrence code 32.

On the next slide, talking about separating ABN; you want to give separate ABNs to patients for procedures performed on different dates and you are going to bill separately for each date involved.  If a provider renders a service not pertaining to an ABN at the same time as the service requiring an ABN, what you are going to do is submit the services on separate claims.  If the time period cannot be separated, what this means is if you have the service requiring an ABN given on the same date as the service not requiring an ABN, you are going to submit the single claim for the overlapping period using occurrence code 32.  You are going to show all services as, covered that is what essentially you will do.  So what happens here because you cannot split claims, the occurrence code 32 does not apply to every thing on the claim.  So what happens, you will then use the GA-modifier on that claim for those services where the ABN was signed.  So that will tell Medicare which ones you have the signed ABN on file for. 

Now I also wanted to point out - I get questions on the GY and GZ modifier, can these be used on the UB-92?  I believe it was April 1, 2003, they were made effective for the outpatient or the OPPS claims.  The GY and GZ modifiers - which we're going to talk about in just a moment, - can be used for OPPS claims.  So I just want to say that before we move on to the CMS-1500 form. Your GA modifier, this is a very, very important modifier for you.  This will be appended to a service for which a signed ABN has been obtained, and this is also going to be used if the patient did not find the ABN, so this goes back to the example we talked about when the patient is presented with an ABN, the patient refuses to sign the ABN, you get two witnesses is to sign it.  You are still going to bill with this modifier, so it is as if the patient has signed it, as far as modifier usage is concerned.  According to CMS, if the GA-modifier is not used, the question of an abusive billing pattern could arise.  So this goes back to the comment I made about the mandatory claims submission provisions and submitting your claims and making sure that you are attaching the appropriate modifiers so Medicare does not think that you are just repeatedly submitting claims to them for services that you know are non-covered or not medically necessary.  Carriers do not use the modifier to determine medical necessity, so just because you attach the GA modifier on there, it does not mean the claim will be denied, essentially what the GA-modifier does is that it lets Medicare know, if indeed this is not medically necessary, I have this ABN on file, so I can bill the patient.  That GA-modifier, what happens when Medicare denies that claim, it then makes it a patient responsibility denial versus a contractual denial, so that is why the GA is so crucial. 

Once again, when I am doing my audits, I have seen so many times where people will go through the time and effort to get the ABN signed by the patient, they will have this on file, it will be valid, they have all their ducks in row.  But on the back end, when it came to billing it, they did not attach the GA-modifier and what happens is Medicare denies it as a contractual.  Then you have to go through the appeal process and send them the ABN and show them that you had it because it was submitted incorrectly.  So it is very important to make sure that when you have the ABN signed that the GA is appended, so you can get the PR denial and then turn around and bill the patient. 

Now the other modifiers that you can use are the GY modifier and the GZ modifier,
which are both optional modifiers.  Your GY modifier, this may speed the rejection of claims, so the provider can bill a secondary payer or the patient.  What the GY modifier is used for is if you have an item or service that is truly non-covered, it is a statutorily excluded service, then you can append the GY modifier to that service.  Typically, this will be used in the instance where you want to bill a secondary payer.  Here is an example of what I have found, because we have this mandatory claims submission provision like I had mentioned before.  I had an instance several years ago where there was a particular diagnostic test that we were billing with a V code, a screening code.  These were submitted to a Medicare carrier, and this is before the GY modifier ever came in to play, and what was happening was we were submitting these claims to Medicare with this V code which should be denied as non-covered and they were paying on it.
 
So, we were getting paid on all these and I would call them and write them and say, you need stop paying us, it is a non-covered service.  No matter how hard I tried, they kept paying us on the non-covered service because they were coded with the V code and we had to keep or returning the over payments.  Finally, when the GY modifier came into play, we started attaching that and that stopped occurring.  They actually were denying the service and we were not getting paid for it.  It is unfortunate that if we get paid in error, even if it is an error on their end, if down the road it gets discovered, we knew about it and we did not return it, then we can pay possible fines.  It just creates a big mess.  I find it interesting that it does not work both ways.  We struggle on the provider side to make money, but if we catch their mistakes, then we need to actually return the money to them.  But that was what was nice about the GY modifier.  Once we started using that, we did not have any problems.  They were getting denied and we could bill the secondary payer or why not, so it did help out. 

The most common examples when you would use these would be routine physicals or maybe your lab or radiology tests when you do not have signs and symptoms for the patient.  ABNs are not required in this case, however the notice of exclusion for Medicare benefits can be used, and that is the third form that is in your packet.  If you look at that, you will see that it is just really reiterating those particular benefits or those particular services that are not Medicare benefits, so this is something that you can use with your patient as well, for a communication tool.
 
Moving along to the GZ modifier, this is an optional modifier as well.  This is used when the provider believes the service will be denied, but an ABN has not been obtained.  So essentially the GZ modifier would be your back-end medical necessity modifier, if you will.  Right before that claims goes out, you have somebody do a check and see whether or not that service - review the LCD or the NCD to determine whether or not the test is medically necessary -  if you determine it is not medically necessary based on how the claim is going out, you are going to look at the chart and see if there is an ABN.  If there is not an ABN, you are going to attach the GZ modifier letting Medicare know, you believe that they will deny it.  Just because you attach the GZ modifier though, once again, the modifier itself does not determine a denial.  GA, the GY and the GZ, just to let you know, because the GY, GZ like I said are optional and then the GA that is just kind to facilitate or communicate to them you have an ABN on file.  So I want you to be clear that by putting these modifiers on there does not 100% mean that it is going to be denied because it is not what they look at. 

Now moving along to the LCD reconsideration process.  I want to talk a little bit about that.  We are coming up on the hour here, so I want to make sure that I get to the rest of these slides that I have.  Beneficiaries and providers can send a request for reconsideration to any LCD and you can ask for modification to any section.  Your most common requests are going to pertain to your indications, limitation on coverage and your ICD-9 codes to support medical necessity.  I would highly recommend taking a look at this process and exercising this process because you can get the content of your LCDs changed if possible.  I have actually had succeeded in doing it with Florida Medicare in the past.

On the next slide, I have some point here about the LCD reconsideration process.  Before I go through these, I am just going to mention that whoever your Medicare carrier is, if you go out to the their Web sites, they all have their instructions posted on their Web sites on how to submit something for reconsideration for an LCD, so every carrier has the instructions posted on their Web site.  The requirements should be the same pretty much from carrier to carrier, so what you are seeing here are the general guidelines that your carrier should be following.  First and foremost it has to be in writing and the request must be supported by evidence; and I can tell you if you do not send this in with your request, they will automatically consider it invalid and send it back to you.  You have to have medical evidence, so you are thinking okay, how do I get peer-reviewed, medical literature, published studies?  Well, you go in to the Internet.  What I would recommend doing if you are dealing with a radiology study, I would recommend going out to the Web site for the American College of Radiology and taking a look at their guidelines as far as the clinical indications for when certain times or exams are ordered - that is considered your medical literature.  I have actually had stuff successfully added, like I said in Florida, based on information I submitted from the ACR Web site.  It is very simple, whatever your specialty may be, going out to may be that Web site to see if they have clinical information for you to use, or just doing a general search across the Internet and seeing what official sources you can find, printing that out and highlighting the sections that are pertinent and then send that in.
 
It also can be helpful if your particular physician wants to put something in writing as well, it cannot hurt.  But, after you compile this information, you are going to send it in and within 30 days of receiving it, Medicare will let you know whether your request is valid or invalid.  If it is invalid, then you go back to square one and you try to see what you can do to get the request to be valid.  If it is valid, they will notify you within 90 days of whether or not they approved your request.  And I have to tell you it is the best feeling in the world to go through this process and actually have a positive result on the end,, knowing that you affected some of these crazy policies.  I am sure that many of you who have been doing this for a while and are working with these polices, when you are coding and you are looking at whether or not things are medically necessary, you say, 'oh, this is a no-brainier, this has to be in the policy, it has to be covered.'  Then when you go to the actual policy, it is not.  It is very interesting how they determine what goes on some of these policies, but you do have the ability to affect this process and I recommend that if you have a particular test that they are doing repeatedly or you are providing a particular service repeatedly where your patients pretty much have the same conditions or same signs or symptoms and they are not on  these covered policies, that you try to get the policy changed.  That way  you do not have to go through all this work on the back-end or write-off the services or go to the patients and collect from the patients.  So if you find there is a particular test that they are denying repeatedly for your patient population, and the problem that they are having a similar, I would actually take the time to go through and do this that will actually help you increase your revenue as well.
 
Now the NCD reconsideration process, you can follow a similar process to get your national coverage determinations changed, although I will tell you the instructions for submitting your request are much more specific and require a lot more documentation, so it is a lot more homework on your end to actually get NCDs changed.  What I did is I put the link on the slide here for you to the actual NCD reconsideration instructions, so whenever you are board, if you have free time in your day, great, you can go out there and you can actually read those instructions if there are any NCDs that you would like to get changed. 

Now with all this information, how do we take all of the information and implement it?  How do we make this work in our facilities and in our practices?  We need to develop some clear policies and procedures and on page 18, you will see that I have a slide titled policies and procedures and those areas that you should address in your policies and procedures.  What I want to do is go down to the next slide with process recommendations, because the process recommendations basically are giving you the tips or the things that you need to consider in writing these policies and procedures.  So really the policies and procedures slide is a list and in the slides after this in process recommendations, those are the nuts and bolts of putting these policies and procedures together. 

So on the process recommendations, first thing we need to consider is who will perform our checks and obtain ABNs.  I would recommend implementing checks at multiple points; you want to have as many people as possible involved in the process.  Obviously the best time to check would be at the time the patient is scheduled for a particular exam, because that gives you time before the patient comes in to maybe go back to the referring physician and say, do you have additional documentation, this test does not meet medical necessity requirements, try to get more information to ensure that the test will be paid from the physician.  You want to try to do that up front, obviously registration, they are going to be those individuals who are actually presenting the ABN to the patient, for the most part registration staff in my experience, usually are not knowledgeable in coding and using LCDs - there are those that are, but by and large I find that they are not.  So that is something where you may not want them to be your first checks, that is why I recommend scheduling.  Also your technologists or your nurses can also be another checkpoint as well. So, if you have multiple people doing that check, then you are more likely to catch those tests that maybe will fall out.  But it is just important to identify at least one individual who ultimately has accountability for making that check.  You may want to consider and FTE with a coding background for your admitting area.  If you are in a hospital, maybe you have a relationship with somebody in the HIM department where you can actually go to a coder and ask for assistance when there is a question.  How will checks be performed? Many people code them manually, but we also have so many software products on the market where you can actually make it an automated process.  You have some software programs that are simply a look-up tool, which will assist you, they have all the LCDs and NCDs loaded, you go the test that you want and check the list.  You have others where you can actually key in a diagnosis code and it will do all the searching for you, some maybe even generate ABNs, there are so many products on the market, so you may want to look into doing an automated process. I will say this: some people look to the software as their ultimate solution.  The software is only as good as the people who are using it.  So if they are not utilizing it appropriately, then it is not going to be your catch-all and it is not going to solve your problems, but it definitely will help.

Obtaining ABNs, we talked a little bit about providing patients with an educational brochure as another thing that you can do.  I know that when I worked for one of the large healthcare companies several years back, they actually had a brochure for patients they gave to them explaining the ABN, why they were getting the ABN and what that ABN form meant. So you may want to put something together for your patients.  There is actually out on the CMS Web site a brochure that CMS put together to give to your physicians that shows an ABN decision tree, which you also may want to check out as well. I just want to point that out. 

On the next slide for process recommendation, you need to consider the action that is going to be taken when your orders are invalid or incomplete.  What you want to do is designate someone to contact your physicians for additional information.  It may be via phone, it may be via fax, whatever works best for your physicians.  I would recommend tracking the invalid, incomplete orders, so you can identify what issues you see repeatedly and also identify those physicians who are problematic and do education. That is very important for you to be able to see, because you will find that some physicians are more problematic than others.
Your post service checks, this is important as well.  We talked a little bit about this.  You want your coders or whoever is assigning the code on the back end to do that medically necessity check.  If at that time medically necessity still is not met for a test, you have the option of obtaining additional information from the referring physician.  Like I said, a lot of times the referring physician will have what we need in his office notes, he just has not given it to us.  So I would recommend taking the time to do that before the claim is submitted, rather than getting a denial ,or if you have an ABN signed by the patient, trying to collect the money from the patient.  You are just really trying to exhaust all options before that claims goes out the door to get it supported, that is how I look at that.  So that is something that you want to take a look at.  Patient financial services and HIM must work together, so your billing department and medical records have to work together to get make sure all the information is there and that these are coded and that it is billed correctly.  You want to also have somebody who is very knowledgeable in doing appeals, somebody with coding knowledge is probably a good choice to do an appeal, also a little bit of clinical knowledge does not hurt and can be very helpful in doing appeals.  Then of course, in your process, you want to do some auditing and monitoring and if possible, you want to audit on a monthly basis, but at least quarterly.  With these audits you want to look for trends, and for those in the hospital, you are going to paper pay particular attention to denials in the emergency department.  Take a look and try to educate your emergency room physicians as to what you need documented in the record to support medical necessity, because it could be that they are just not giving you enough documentation, and if it is simply beefing up the documentation a little bit to get these paid, then it could be a very easy fix.  Because once again, that is a very tough area to get paid in, and they are usually writing a lot of the 'rule out' information as well. 

Another thing you want to do, you want to have your policies and procedures or as a process recommendation: submit comments for draft LCDs and LCDs reconsideration.  I did not mention the draft LCDs a few slides back, but hopefully you all have seen when you go out to your carrier's Web site, that there is actually a section where they post the draft LCDs and you actually have a designated time period to submit comments to those LCDs.  So I encourage you to keep up with those and go out there and see what they have posted as a draft and give your 2 cents before it becomes a final policy.  It is a lot easier to do at that point and get considered then to go back and go through the reconsideration process on the back end, so that is something you want to keep up with. 

On the last few pages here we have some tips about working with physicians, working with staff and talking to beneficiaries.  For working with your physicians, it is really key that you educate the physician on all the requirements that are out there for diagnostic test orders.  The physicians always want to see it in writing; if you tell them, 'oh Dr. so and so, you have to do this, it is Medicare requirements, it is this requirement, it is that requirement.'  They always want to see it in writing.  They will not believe you until they see it, and hopefully after they see it in writing, they will comply with it, but you want to give them a written summary of authoritative sources, and you can find this information in the Federal Register, the BBA and of course in the CMS manuals. 

You want to establish a good rapport with the staff at the each physician's office, because let's face it, when you are calling them and trying to get additional information, you are not talking to the doctor.  You are talking to the people in the office and you want to educate them and work with them if they are the ones who may be completing requisitions - if you have happen to use requisitions rather than just the doctor sending over his own prescription pad with what he is ordering, you want to work with them and make sure that they are giving you what you need on those.  You also want to try to identify a point person at each office that can assist in providing additional information.  This could be whether you have an incomplete order, you are appealing a denied claim, you want additional notes from the physician, etc.  But try to find like one person that you can go to for that to make it easier on you and then consistently they will know what you are going to need. 

It is also recommended that you share copies of the LCDs with the referring physician and you want to instruct the office staff on how to utilize them - or the doctor if he is going to be the one looking at them - if you have medical necessity software, like some facilities right now, some of the physician groups are online with you, they can like log on and see patient information and things like that and they already have access to a lot of resources at your facility.  If you have this medical necessity software, then you may want to give them access to it as well to do these checks on their end before they send the patient over.  Because in theory the ABN should be generated from the referring physician in the referring physician's office.  But it does not happen, because the referring physician usually is not very concerned because it is not going to affect them financially.  They are not the ones that are going to get paid for the test. But if you are the one who has the liability for the tests if they are not paid, then it is always in your best interest to get that from the patient.  So it really has fallen back on the facility or the practice providing the actual service. 

Also under working with physician #5, you want to make sure that your standard requisition are user friendly and accommodate all required information for written orders.  After reviewing all the requirements for written orders, make sure that your form is compliant with them.  I have seen forms where they do not have a space for the doctor to write a diagnosis or signs or symptoms, or there is no space for the doctor to provide a signature.  If you are not prompting the doctor to give it to you, he is not going to give it you.  So that is something you want to take and look at.

Consider appointing a physician liaison to work with the physicians one-on-one to assist them in working with the facility.  So if you have that ability, if you have a person who can do that, that is highly recommended.  Working with your staff, you want to educate the appropriate staff on the federal rags and the CMS requirements for the ordering of diagnostic tests and services, and of course you want to select those individuals who need training on the use of ABNs, how to look at those NCDs and LCDs to determine whether or not a service is medically necessary.  You want to customize the reasons on the ABN forms, like I have mentioned earlier, because you are going to have different individuals getting the forms. This will help with consistency and in making sure that your ABNs are valid and compliant.  So customize those reasons where the staff just has to check them off.  It will make it a lot easier for you.  You also want to provide staff with copies of the NCDs and LCDs if you are not using software or if you are using software, it is not going to be a bad idea to have a paper copy as well.

On our last slide here, beneficiary education, the whole downside to this medical necessity thing is that Medicare makes the providers responsible for explaining medical necessity coverage rules to beneficiaries.  If you ever go out and take a look at the information that is given to Medicare beneficiaries, it just briefly touches on medical necessity and ABNs -it is very very minimal, what CMS has actually published for Medicare beneficiaries.  So it really falls back on us providers to educate the beneficiary.  The LOL, the limitation on liability and RR, the refund clauses, those require the beneficiaries to know that Medicare may not or may deny a service because it does not meet medical necessity rules.  So that goes back to the financial liability provision.  If you go out to the Medicare Web site, the Medicare.gov which I have here, there is a brochure called, 'your Medicare rights and protections' and this is where the ABN is briefly explained to the patient.  So it is helpful, so this is something that you may want to actually print out and have handy for your patients.  This is good information to use as a starting point and developing your own patient education tools, or even helping your staff in discussing medical necessity and ABNs with Medicare beneficiaries.

So it is about 12:15, so I would like to give you all an opportunity to ask some question, I know that we have covered a lot of material.  I hope that it is helpful and if for some reason if we do not get to your question if we have many, my contact information is on the last page here, the last slide page 22, you can e-mail, you can call me and I will more than happy to answer any of your questions or provide you with additional reference, so that is end, Mandy, I would like to open up the lines for question.

Thank you Ms. Buck. Ladies and gentleman, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press *1 on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue please press #.  Please limit yourself to one question at a time, so that everyone may have a chance to participate.  If you have another question, you may re-enter the queue by pressing the *1.
 

Q & A Session:

Question:  We are urologists and we give an injection to a patient called Lupron Depo, which is the leuprolide.  We are also a least costly alternative to the state, so we use the Lupron medications, but Medicare lowers the price down to the Zoladex prices, which is a difference of $253.36 for the patient.  Should they sign an ABN because we are denied by Medicare, they lowered the rate and this is a difference that our doctors want to collect, or should that meet a notice of exclusion from Medicare benefit?
Answer:  So, what is their coverage guideline for that particular drug?
Comment:  They just changed it this year as of January and  the consult changes every four months.
Answer:  Okay, so you are talking about the actual reimbursable amount.
Comment:  Correct.
Answer:  That the reimbursement has just decreased - that is actually a problem that a lot of providers have now with this methodology for computing reimbursements and unfortunately there is not a way for you to collect the difference from the patient for that reimbursement, so that is not a situation where the ABN would apply.
Comment:  So we had one time where we put the GA on the medicine and they lowered the price down;  one time we did not put a GA on the medicine and they paid the Lupron rate?
Answer:  Really.
Comment:  Yeah.
Answer:  That is very interesting. 
Comment:  We are totally confused because, we used the GA and get paid the higher or not get paid higher or is it a fluke by Medicare that they paid us at the higher rate.
Answer:  I would have to say that it was probably just a fluke that you did get paid the way, it should not matter, that modifier should not affect the amount that you are getting reimbursed for that drug.  So I mean that is something if you want to contact me, I can look into the further for you, if you would like to give me more specific information and I will be more than happy to do some research, but it just sounds like for some reason, they are not processing the claim correctly on their end.
Comment:  Should we be using the GA on the medication?
Answer:  Well, I would not see why there would be a need to get the ABN for the medication, unless you knew for whatever reason the medication would not be covered at all.
Comment:  No it is  covered, because it is for prostate cancer and so it is a covered entity, but it is new rule with Medicare, the government, with what their reimbursement is, they hit this drug.
Answer:  Right, they changed the reimbursement methodologies for a lot of  drugs and what happens is some reimbursements for drugs have increased significantly and others have been reduced significantly, but there isn't a mechanism for billing the patient for the difference.
Comment:  Okay, maybe I will fax what we have gotten from EOBs, you could give some advice on what to do on that.
Answer:  Yeah, I would like to see that if you just want to blank out the patient information and all that and just give me the pertinent information, I will be more than happy to take a look at it for you.

Questions:  Hi Stacie, I have two questions that were sent in by email.  The first one asked what is the difference between an LCD and LMRP?
Answer:  Okay, that is a good question that is actually a question that I have had come up a few times.  I know historically we all have heard the term LMRP, and then recently we have heard the term LCD, which is the term that I was using today all throughout the presentation.  But some people also use them interchangeably.  Basically what is happening is CMS has said that all of the Medicare contractors have to convert from LMRPs ,local medical review policies, to these local coverage determinations by October of 2005.  The difference is that the LCDs are only focusing on the reasonable and necessary information, so the LCDs are not going to contain all of this other information that we have seen historically in an LMRP, so the LCDs are now focusing more on medical necessity.  The other information that has been communicated in LMRPs will now be found in your Medicare bulletins; also I have seen some of the Medicare carriers on their Web sites, some of them are kind of like half way through the conversion, where they some LMRPs that are already converted to LCDs.  At the bottom of their LCDs, it actually has a link maybe at the top of the LCD to a separate document where you have coding guidelines for that particular service, so essentially what they have done is they just pulled out the medical necessity information.  They made it more like an NCD release, so it is kind of like standardizing those.  The other information can be found in your bulletins, and also maybe as a separate link, some of your carriers are doing that.  So hopefully that answer the question.
Question:  Thank you and the last question I have as where I can find information on the CMS Web site on ABNs?
Answer:  Okay, the CMS website, the best place for you to go that will have links to all of this information.  If you go out to cms.hhs.gov/medicare/bni  that will take you to the beneficiary notices initiative page and that will actually have all of the forms that are out there, all of the ABN forms, not just the ones we talked about today.  It will also have that information brochure that I mentioned that is available for the physicians that you can take a look at.  So that is a very important tool for you to have.  It also will have a link to the instructions for ABN use, which are contained in section 50 of chapter 30 and the Medicare claims processing manual.  So you can either go to this BNI page and link to that or you could just simply go to the manual link and then go to the Medicare claims processing manual and go to chapter 30 and then look up the information that pertains to the BNI and these ABNs.  So once again if you go to www.cms.hhs.gov/medicare/bni, that will give you links to all of this information.

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