Orthopedic Coding Alert

Question: I keep hearing the term "NEMB," but I-m not exactly sure what it is. I know that it's similar to an advance beneficiary notice (ABN) but that it isn'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 ABN in that the ABN is for services Medicare might cover but will most likely deny on the grounds that the patient does not fit the medical-necessity requirements for the service to be covered. NEMBs (CMS form CMS-20007) inform patients when Medicare will not cover a service 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 be (ABN) or will be (NEMB) financially responsible. Using an NEMB is optional, and CMS developed the form to assist in informing Medicare beneficiaries that Medicare benefits exclude the service they are receiving.

Example: A scenario in which a practice might use an NEMB would be when they are performing a purely cosmetic, elective procedure, which Medicare never covers. By using an NEMB, the practice informs the patient that the service is never covered and what the expected costs will be. Medicare does not require the NEMB as it does the ABN, but using the NEMB is good business and increases the probability of collecting from the patient.

Bonus resource: You can find a sample NEMB at www.cms.hhs.gov/BNI/11_FFSNEMBGeneral.asp.