Pediatric Coding Alert

Alleviating write-offs for noncovered, same-day E/Ms, phone care, screenings and vaccines might be as easy as A-B-N.

That's an advance beneficiary notice (ABN), which is Medicare's version of a financial waiver. You have the patient's guardian sign the form at the time of service and collect the charge for a noncovered service. Sound simple? It is -- if you watch out for these pitfalls.

You can charge a patient for a service only when the insurer considers the item noncovered. If the plan denies the service as bundled or covered in another service, you can't bill the patient for the denied item, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Example: An insurer denies FluMist administration as noncovered due to Medicare's perception that patients self-administer intranasal sprays. You can charge the patient for the vaccine administration (for instance with 90467, Immunization administration younger than age 8 years [includes intranasal or oral routes of administration]; when the physician counsels the patient/family; first administration [single or combination vaccine/toxoid], per day).

Obtaining a financial waiver protects you if an insurer denies coverage of an item. "We use it for items that we know are not paid by all insurance companies, as well as a few items that we know certain insurance companies do not cover in our office," says Sharon Maylum, RN, clinical manager at NW Dayton Pediatrics in Ohio. For instance, "We use them for all 'behavioral' discussions" because due to mental health carve-outs, some insurers do not cover these in a pediatric office.

The ABN alerts the patient that he may have to pay for an item "out of pocket," such as 99214 (Office or other outpatient visit for the E/M of an established patient ...) for physician behavioral counseling, for instance on thumb-sucking (307.9, Other and unspecified special symptoms or syndromes, not elsewhere classified). That way, the patient should not be shocked when his insurance denies coverage and he receives a bill from the pediatrician, Maylum says.

Best practice: Give your patient an accurate cost estimate, which Medicare will require on its new form as of Sept. 1. That way, a patient can determine if she wants to have the service.

You can use a home-grown form for private payers, says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, in "ABN and Medical Necessity Essentials" presented by AudioEducator.com. Experts recommend using a version of the national standard form, CMS-R-131, which you can download from http://www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf. Substitute your insurance company for any mention of government insurance.

Gone: If you heard that in lieu of an ABN you sometimes need to use a notice of exclusions (NEMB), you can forget this requirement. Medicare previously required this form for services that Medicare statutorily excluded, such as preventive medicine services (99381-99397). Carriers will not accept this form after Sept. 1.

If an insurer usually considers a service noncovered under the met criteria, you can have the patient sign a waiver, collect payment up-front and still submit the item to the insurer. If the payer does cover the service, you can refund the patient the applicable amount.

At Dayton Pediatrics, staff does not enforce the pay-up-front policy. "We bill the patient if we receive an insurance denial for 'noncovered' service," Maylum says.

Example: You know UnitedHealthCare will cover otoacoustic emissions (OAE) (92587, Evoked otoacoustic emissions; limited [single stimulus level, either transient or distortion products]) only when a patient has a medical diagnosis, such as 389.10 (Sensorineural hearing loss, unspecified). But at preventive medicine services (such as 99392, Periodic comprehensive preventive medicine reevaluation and management of an individual ...; early childhood [age 1 through 4 years]), during which you recommend OAE screenings, you explain the service's benefit to the member.

You tell her, "If the child doesn't have a problem, you will be responsible for payment, which is $XX."

"The ABN also gives the patient the option to refuse the service, and if this is the case, we do not provide it," Maylum says.

When billing patients post-denial, "use Medicare HCPCS modifier GA (Waiver of liability statement on file) on the claim," Buck says. Although the payer might not recognize the modifier, it will alert your billers to charge the patient for the service and not automatically write off the charge.

Example: Before your pediatrician offers telephone care using the new 2008 codes (99441-99443), your front-desk receptionist explains to the patient's mother that if she opts for this service, rather than coming in for a visit, you will charge a flat fee to her insurer that she will be responsible for paying if her plan considers the service noncovered. The receptionist notes the mother's acceptance in the system, and the coder uses "GA" in field 24D of the CMS form with the appropriate time-based telephone code, such as 99442 (Telephone E/M service provided by a physician ... 11-20 minutes of medical discussion). The insurer denies 99442-GA as noncovered, and the biller reviewing the EAB remittance note sends the patient a bill.

"Notification may be via phone," Buck says. You should follow up with a signed form.