Ophthalmology and Optometry Coding Alert

Question: For what codes or procedures should I use the "Medicare Noncovered Services Release Form"?

Michigan Subscriber

Answer: You should use one of two types of forms depending on why you don't expect Medicare to pay for a procedure. Suppose a recently established 55-year-old male patient requests a glaucoma screening exam. Because Medicare will cover screenings only for high-risk patients, and you are unsure whether this patient meets the "high-risk" definition, you ask the patient to sign an ABN. The ABN describes the service the ophthalmologist will provide and the possible reason Medicare will reject payment.

When the patient returns the test, you report the service using G0117 (Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist). Append modifier -GA (Waiver of liability statement on file) to G0117 to indicate you have a signed ABN on file. If the patient is not high-risk, Medicare will deny the claim, sending the patient an evaluation of benefits (EOB) explaining that the service is not covered. You should collect the patient's payment for the service at the time of his next visit.

If you know Medicare doesn't reimburse a code because the service is not a Medicare benefit or the law excludes coverage, you should use form CMS-20007, "Notice of Exclusions from Medicare Benefits" [NEMB]. For a service that Medicare does cover but for which you don't expect Medicare to pay due to the patient's particular circumstances (such as medical necessity or frequency of service), you should instead have the patient complete an advance beneficiary notice (ABN).

When you use an NEMB, the form alerts the patient that Medicare won't cover the service or procedure. You could use an NEMB to tell a Medicare patient that his insurer won't pay for a routine service, such as 92015 (Determination of refractive state). If you're unsure whether Medicare will cover a procedure, you should instead use an ABN.

For copies of NEMB and ABN forms, visit www.cms.hhs.gov/medicare/bni.