Wiki Statutory Exclusion for Medicare

[Hite]

Is it appropriate to bill statutory excluded CPT codes to patient with a reduced Charge from the charges that you would normally bill to Medicare. Example 17110 with benign skin lesion which is considered cosmetic and as such is not covered by Medicare program (statutory exclusion). If billing to Medicare the charge would be $210.00 but patient has been given a voluntary ABN and she has choosen to pay for services and not bill Medicare and looses her appeal rights and since patient has choose this option, is it appropriate or legal to only charge the patient a $75 fee at time of service? Also if you could provide documentation supporting your answer.

 

[Skymom]

Maybe this will help guide you:


Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections

50.7.3 - Effects of Lack of Notification, Medicare Review and Claim Adjudication
(Rev. 2782, Issued: 09-06-13, Effective: 12-09-13, Implementation: 12-09-13)
A. Beneficiary Liability
A beneficiary who has been given a properly written and delivered ABN and agrees to pay may be held liable. The charge may be the supplier/provider’s usual and customary fee for that item or service and is not limited to the Medicare fee schedule. If the beneficiary does not receive proper notice when required, s/he is relieved from liability.
Notifiers may not issue ABNs to shift financial liability to a beneficiary when full payment is made through bundled payments. In general, ABNs cannot be used where the beneficiary would otherwise not be financially liable for payment for the service because Medicare made full payment. See 50.13 for information on collection of funds.