Pulmonology Coding Alert

If youre about to perform a procedure that your carrier may not consider medically necessary, you must obtain a signed advance beneficiary notice (ABN) from your patient beforehand. You then submit the bill with the appropriate code, and if its refused, you can collect from the patient.

According to the Medicare Carriers Manual, an ABN allows a beneficiary to make an informed consumer decision by knowing in advance that he or she may have to pay out-of-pocket.

The Office of the Inspector General (OIG) for the Department of Health and Human Services (HHS) has released its work plan for fiscal year 2001. It states, Indications are that practices vary widely regarding when ABNs are provided, especially with respect to noncovered laboratory services.

Not Medically Necessary or Not Covered?

If the procedure in question is not covered by Medicare or your carrier, theres no need for an ABN. It wont be reimbursed, regardless of the diagnosis. If a test is considered routine screening, for example, it wont be paid. Although an ABN isnt required before you can bill the patient for the service, you should inform the patient that he or she will be responsible for payment.

But there are gray areas in the question of medical necessity. Some procedures may be medically necessary for one patient and not for another.

Quin Buechner, CPC, MS, M.Div., coding consultant, ProActive Consultants, Cumberland, Wis., says, Medical necessity is defined by the insurance carrier from a payment perspective. Good medicine may not always be the same thing as paid-for medicine. Coders must know what the carriers think is medically necessary. When Medicare doesnt think its medically necessary, an ABN is essential.

Buechner points out, for example, that a spirometry (94010, spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) is never covered if its taken for a baseline. A healthy baseline may be good medicine, but it wont pay.

Another example is 94150 (vital capacity, total [separate procedure]). Again, if its just for a healthy baseline, it wont be covered. The diagnosis makes the difference between payment and denial. Also, there are areas in which the physician and the carrier may differ. Buechner says, A physician may believe he or she has a rational diagnosis, which is a good reason to order the test. But the carrier may disagree and rule that the diagnosis doesnt justify the test.

Coders should also know how many visits per month their carrier will pay for. The physician may believe the patient needs more than the carrier will cover. Buechner advises, Give your billing staff enough time to take a good look at what the carrier accepts. If youre in a hurry, and in doubt, obtain an ABN but you must avoid always being not sure.

The Diagnosis Justifies Medical Necessity

Carol Pohlig, BSN, RN, CPC, of the Hospital of the University of Pennsylvania department of medicine in Philadelphia, says that medical necessity relates to the appropriate ICD-9 code used on a claim. Covered ICD-9 codes for certain procedures are sometimes published in medical policy bulletins.

Pohlig cites the example of bronchoscopies performed for photodynamic therapy. To bill for bronchoscopic photodynamic therapy, report 31641 (bronchoscopy with destruction of tumor or relief of stenosis by any method other than excision [e.g., laser]) in addition to 96570 (photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]).

This procedure is only considered to be medically necessary for pulmonologists, Pohlig says, when performed for malignant neoplasms of the trachea (162.0); main bronchus (162.2); upper lobe, bronchus or lung (162.3); middle lobe, bronchus or lung (162.4); lower lobe, bronchus or lung (162.5); other parts of bronchus or lung (162.8); bronchus and lung, unspecified (162.9); secondary malignant neoplasm of the lung (197.0); carcinoma of the trachea (231.1) or bronchus and lung (231.2). She warns that If any other ICD-9 codes are used for this procedure, the claim will most likely be rejected for medical necessity issues.

No Blanket ABNs

With so much uncertainty surrounding the use of the ABN, it might be tempting to obtain a blanket ABN for all future services, just in case theyre not covered. But Medicare wont accept a blanket ABN. Pohlig says, An individual ABN must be signed before each procedure or service that the doctor thinks may not be considered medically necessary by the insurer.

HCFA issued a program memorandum (A-00-43) to clarify the use of ABNs. For example, it requires the ABN to be signed in advance of the service. It states, A patient must be notified well enough in advance of receiving a medical service so that the patient can make a rational, informed consumer decision. Information provided in advance must include costs.

HCFA also states, ABNs given to any individual who is in a medical emergency or otherwise under great duress cannot be considered to be proper notice.

Add the -GA Modifier

Pohlig reminds coders that Its a good practice to add a -GA modifier (waiver of liability statement on file) to the claim to alert the carrier that an ABN is on file. This may help to prevent the beneficiary from claiming that he or she never signed a waiver.