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Urology Coding Alert

READER QUESTION:

Capture Self-Pays With NEMBs

Published on Tue Feb 13, 2007

Question: I keep hearing the term NEMB, but I'm not sure what exactly it is. I know that it's similar to an advance beneficiary notice but that they aren'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 advance beneficiary notice (ABN) in that the ABN is for services Medicare covers when provided for certain diagnoses or within a certain time-frame, but will most likely deny on the grounds that the patient does not fit the medical-necessity requirements or falls outside the specific utilization period for the service to be covered. NEMBs (CMS form CMS-20007) inform patients when Medicare will not cover a service EVER and under no circumstance, because that service is not a Medicare benefit.

Difference: Both forms allow patients to make an informed decision about pursuing treatment, with the knowledge that they may (ABN ) or will be (NEMB) financially responsible.

Using an NEMB is optional, and CMS developed the form to assist in informing Medicare beneficiaries that the service they are receiving is excluded from Medicare benefits.

Example: Medicare will not cover custodial care or a "checkup examination" unrelated to a diagnosis or treatment of a specific illness, symptom, complaint or injury, or a checkup required by someone, such as an insurance company, business, school or governmental agency. If the patient is not sick, there will be no coverage. In addition, Medicare does not reimburse for purely cosmetic surgery such as for a penile augmentation procedure.

Good idea: While it is not necessary for you to provide the patient with prior notification of this non-covered service, it may be a good-will gesture to do so before performing the service. Some practices post this information at the front desk and in the exam rooms while others provide the patient with the NEMB with the amount of patient financial responsibility listed on the form. Some practices also use a highlighter on the form for these two areas to make them easily visible to the patient, as the form lists many other noncovered services.

Record keeping: You don't have to have the patient sign the form or keep it on file in your office. The NEMB can simply be filled out and given to the patient.

Important: Although this is a noncovered service, if the patient has a secondary insurance and asks you to submit a claim to Medicare in order to get a denial notice, you should submit the charge with modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit). This tells Medicare that you are aware the service is noncovered but require a denial for filing to a secondary insurance or at the request of the patient.

Note: For Medicare, append modifier GA (Waiver of liability statement on file) to services your physician provides to a patient who has been informed in advance of the possibility of noncoverage via the ABN and has agreed to accept financial responsibility in this event.

Bonus resource: Find a sample NEMB online at www.cms.hhs.gov/BNI/11_FFSNEMBGeneral.asp#TopOfPage.

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