Pulmonology Coding Alert

Question: Sometimes a patient comes in for surgery and our doctors order a pre-op EKG or some other procedure that we know in advance Medicare will not pay because it deems the procedure non-covered. This means we have to let Medicare know that the patient should be billed directly. After the patient agrees to be responsible for the procedure, we have them sign a disclaimer. The EKG procedure, for instance, then is coded with modifier -GA to indicate Medicare should bill the patient for the EKG. Often, however, our doctors will write-off the costs of the EKGabout $53because they believe the procedure was necessary, especially if the patient was a referral.

Is this scenario common? If not, how would we improve our reimbursement efforts here?

California Subscriber

Answer: Unfortunately, there is no national policy or direction on this, and apparently there is great disparity between the Medicare carriers in different states on whether to pay for pre-op exams. One Medicare carrier, United HealthCare, announced that on Oct. 31, 1999, they would stop paying if pre-op diagnosis codes V72.81 (preoperative cardiovascular examination), V72.82 (preoperative respiratory examination), V72.83 (other specified preoperative examination) and V72.84 (preoperative examination, unspecified) are used. This may explain denials if you live in Connecticut, Minnesota, Mississippi, Virginia or New York City.

The Health Care and Financing Administration (HCFA) was forced to issue a clarification because of the numerous complaints about the recent United HealthCare stance. Robert Berenson, MD, HCFAs director of the Center for Health Plans and Providers, says the agency is committed to ensuring that Medicare beneficiaries continue to receive all medically necessary pre-op care.

The entire process of using a waiver allows physicians to perform services and collect money from the patient if the services are deemed non-covered by a carrier. If the physician feels the service should be considered medically necessary, make sure he or she is giving you the correct diagnosis to support that service. Some pre-operative screenings are covered if the patient has underlying medical conditions, but those conditions must be listed on the claim form along with the diagnostic code for the pre-operative screening. Each carrier has specific lists of valid diagnoses, as well as requirements for the order the diagnoses are listed on the claim form. Check with your carrier to determine the most appropriate way to list these services.

Your physicians must understand, however, that even if he or she feels a pre-operative EKG is necessary on every patient, the Medicare program is not funded to pay for those services. In the non-covered cases, the doctor is to provide an advanced beneficiary notice (ABN) to the patient, and the patients who agree to the service are responsible for the bill.

In some states, Florida for example, some Medicare carriers still recognize V72.81 as a medically necessary diagnosis for payment. If your physician believes that the pre-op EKGs performed were medically necessary, you should follow the appeal process for your carrier.

Physicians too often accept a carriers denial as
medically unnecessary and write off their services. Carriers count on that. Initiate the appeal process. Gather together all your pre-op EKG denials and fight for the money that is rightfully yours.

Answers to these questions and to the "You Be the Coder" question were provided by Cynthia DeVries, RN, BSN, CPC, a member of Global Success, Inc.'s Blue Ribbon Panel in Fort Myers, Fla.