Orthopedic Coding Alert

Deciding when to get patients to sign an advance beneficiary notice (ABN) isn't always easy, but local coverage determinations (LCDs) and national coverage determinations (NCDs) can help.

Use these steps to decide if the service fits the insurer's medical-necessity rules:

- Look at the physician's order or patient's prescription to find out whether that test or service has an NCD and/or LCD. If there are no coverage limitations, the patient doesn't need an ABN, and you-re in the clear.

- If you find a relevant NCD or LCD and discover that the service or test does have limited coverage, review the diagnosis or signs and symptoms that prompted the physician to order the test, and decide whether the policy covers that indication.

- If you find that the service does not meet the medical-necessity requirements, and the signs and symptoms or diagnosis is not on the covered list, you should have the patient complete an ABN.

Tip: Be sure to check for frequency limitations. If an LCD places a limitation on a service and the patient exceeds it, you-ll need to issue an ABN.

Hint: Keep in mind that Medicare usually relies on the primary diagnosis code to make the appropriate medical-necessity determination. CMS defines medical necessity as "the determination of a service that is reasonable and necessary for the diagnosis of illness or injury, or treatment of a malformed body member."