Primary Care 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. 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 physical, such as 99397 (Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender- appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; 65 years and over).

You could also alert a patient to Medicare's routine foot care noncoverage with an NEMB. For instance, a Medicare patient without a systemic condition or qualifying symptom requests that your family physician (FP) pare two of her calluses. You know Medicare won't cover the procedure, so you have the patient sign an NEMB form to acknowledge that she is responsible for payment. You report the procedure with 11056 (Paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus]; two to four lesions) and collect cash up front for the procedure.

If you're unsure whether Medicare will cover a procedure, you should instead use an ABN. Suppose a recently established 55-year-old male patient requests a colon cancer-screening exam. Although the patient has had screenings in the past, he doesn't recall when the last screening occurred and his previous medical records are unavailable. Because Medicare will cover screenings only once every 12 months, and you are unsure of the last screening's date, you ask the patient to sign an ABN. The ABN describes the service the FP will provide (a fecal-occult blood test) and the possible reason Medicare will reject payment (excessive frequency).

When the patient returns the test, you report the service using G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations). You append modifier -GA (Waiver of liability statement on file) to G0107 to indicate you have a signed ABN on file. In this case, the patient has exceeded frequency guidelines, and Medicare denies the claim, sending the patient an evaluation of benefits (EOB) explaining that the service is not covered. [...]