Ophthalmology and Optometry Coding Alert

Question: I keep hearing the term NEMB, but I'm not sure what exactly it is. I know that it's similar to an advance beneficiary notice, but that they aren't the same thing. Can you tell me what an NEMB is and when I would need an ABN versus when I would need an NEMB?


California Subscriber

Answer: A notice of exclusions from Medicare benefits (NEMB) differs from an advance beneficiary notice (ABN) in that the ABN is for services Medicare covers when provided for certain diagnoses or within a certain timeframe, but will most likely deny on the grounds that the patient does not fit the medical-necessity requirements or falls outside the specific utilization period for the service to be covered.

NEMBs (CMS form CMS-20007) inform patients when Medicare will not cover a service EVER and under no circumstance, because it is not a Medicare benefit.

Difference: Both forms allow patients to make an informed decision about pursuing treatment, with the knowledge that they may (ABN ) or will be (NEMB) financially responsible.

Using an NEMB is optional, and CMS developed the form to assist in informing Medicare beneficiaries that the service they are receiving is excluded from Medicare benefits.

Example: Medicare has specified CPT Code 92015 (Determination of refractive state) as a noncovered service (benefit) for Medicare beneficiaries and it is not included with other ophthalmic procedures performed in the patient exam for E/M (99201-99215) or eye (92002-92014) codes. You may bill this procedure and collect directly from the patient at the time the service was rendered.

Good idea: While it is not necessary for you to provide the patient with prior notification of this non-covered service, it may be a good-will gesture to do so before performing a refraction. Some practices post this information at the front desk and in the exam rooms, while others provide the patient with the NEMB and the box Routine eye care, eyeglasses and examinations selected, with the amount of patient financial responsibility listed on the form. Some practices also use a highlighter on the form for these two areas to make them easily visible to the patient, because the form lists many other noncovered services.

Record-keeping: You don't have to have the patient sign the NEMB form or keep it on file in your office. The NEMB form can simply be filled out and given to the patient.

Important: Although this is a noncovered service, if the patient has a secondary insurance and asks you to submit a claim to Medicare in order to get a denial notice, you should submit the charge with modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit). This tells Medicare that you are aware the service is noncovered but require a denial for filing to a secondary insurance or at the request of the patient.

Note: For Medicare, append modifier GA (Waiver of liability statement on file) for services your physician provides to a patient who has been informed in advance of the possibility of noncoverage via the ABN and has agreed to accept financial responsibility in this event.  

Bonus resource: You can find a sample NEMB online at www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf.