Medicare has very specific rules when it comes to their beneficiaries being made aware of their financial responsibility. I find that many physician staff members are confused about how and when the Advanced Beneficiary Notice (ABN) is to be used.

Medicare has identified certain codes that have ‘limited coverage’. ‘Limited coverage’ means that the code is sometimes paid for by Medicare and sometimes not paid for by Medicare due to medical necessity. For codes with ‘limited coverage’ medical necessity may be shown with a diagnosis or a time factor. Some of these codes are only paid for if certain diagnoses are used. If the patient does not have one of the approved diagnoses then Medicare will not pay for that service. Other codes with ‘limited coverage’ are only paid for periodically such as once every 12 or 24 months. If the appropriate time has not passed, Medicare will not pay for the service as it is too soon to have this service repeated as far as they are concerned. For example, Medicare will pay for a well woman once every 12 months if the patient is considered ‘high risk’ by Medicare. If the patient is not considered ‘high risk’ then Medicare will pay for this service once every 24 months. If you repeat this service, even 1 month, too soon Medicare will not pay.

Medicare has provided physicians with two Advanced Beneficiary Notices. One is the general ABN and the other is for laboratory services. These forms must be filled out by the physician’s office and signed by the patient PRIOR to the patient receiving the service. If this form is not filled and signed prior to the service the physician may not ask for payment from the Medicare beneficiary. Basically, the physician just performed the service at ‘no charge’ to anyone. The patient will not be responsible because they were not educated concerning their financial responsibility before the service was performed and Medicare will not pay if they do not consider the service medically necessary.

The physician can only ask the patient to sign the ABN if necessary. Your office cannot have every Medicare patient who walks thru the door sign the ABN ‘just in case’. Medicare considers this abuse. Remember that the ABN must be filled out by your office before you ask the patient to sign. The form has a place for you to describe what the service is and why Medicare is not expected to pay for it. If these two areas are not filled out before you ask the patient to sign then you are not using the forms properly and can be sited for abuse.

If the patient signs the ABN and is made aware of their financial responsibility you may require the patient to pay for this service on the date the service is provided. You may also charge the patient 100% of your fee. You do not have to reduce your charge to the Medicare allowable.

When billing a service to Medicare that you have obtained an ABN for you should attach the –GA, -GY, or –GZ modifier to the charge. These modifiers let Medicare know that you have a waiver in place for this service. When the patient receives the MEOB it will show your fee for this service as the patient’s responsibility to pay. If you fail to include one of these modifiers the MEOB will show that it is not the patient’s responsibility to pay and the patient will want a refund if they have already paid you.

Keep in mind that physicians and Medicare very often have different thoughts about medical necessity. When it comes to the Medicare reimbursement a practice has to be concerned with what Medicare considers medically necessary so that the proper forms can be obtained to insure your right to collect from the patient.

Over 400,000 smokers die each year from smoke related diseases. About 300,000 of those are Medicare patients age 65 and older. Research shows that about 10% of the total program costs for Medicare for 1997 were related to smoking. The U.S. Surgeon General has reported that quitting smoking leads to significant risk reduction and other health benefits even in older people who have smoked for years.

Medicare has a benefit that began on March 22, 2005 that can help beneficiaries ‘kick the habit’. This benefit is available to beneficiaries who have an illness caused by or complicated by tobacco use. These illnesses make up the bulk of the Medicare expenditures today, according to Medicare. Beneficiaries who take medication whose effectiveness is complicated by tobacco use are eligible for this benefit. Medications including insulin and some meds used to treat high blood pressure, blood clots and depression are examples. Illnesses such as heart disease, cerebrovascular disease, multiple cancers, lung disease, weak bones, blood clots and cataracts are examples of those that can get coverage for smoking and tobacco use cessation.

Medicare pays for two cessation attempts per year. Each attempt includes four intermediate (3-10 minutes each) or intensive sessions (longer than 10 minutes each) up to eight sessions in a twelve month period. Medicare recognizes HCPCS codes G0375 and G0376 for these visits. The diagnoses are carrier specific. The co-pay/co-insurance and deductible do apply for this benefit.

Your office may be losing out on some reimbursement if you are performing theses services and not charging Medicare for them. HCPCS code G0375 will reimburse from about $11.00 up to over $13.00, depending on the locality, for the 3-10 minute counseling session. G0376 reimburses between $21.00 and $28.00, depending on the locality, for a counseling session over 10 minutes. Physicians and other Medicare-recognized providers can provide these counseling services.

Prior to 1998, 99211 was the most under used code in this country. This is no longer the case. Many physician offices are using this code commonly referred to as a ‘nurses visit’. Many insurance carriers are watching this code. Before entering this code on the claim form be sure the documentation is correct. Common problems with the documentation are no chief complaint, no review of systems, or no plan of treatment. In some cases, medical necessity is not even established.

Documentation for the 99211 should include the rationale for ordering tests, past and present diagnoses, health risk factors, patient’s progress and response to treatment, any changes in the treatment plan, and revision of diagnosis.

Physician Quality Reporting Initiative (PQRI) is an incentive offered by Medicare to Medicare providers. PQRI will focus attention on quality of care. This program is paving the way for Pay for Performance.

Providers will use Category II codes, modifiers and temporary G-codes to report 74 unique measures associated with clinical conditions that are routinely represented on Medicare Fee for Service claims. The measures address various aspects of quality of care associated with prevention, chronic care management, acute episode of care management, procedural related care, resource utilization, and care coordination.

Some measures have a Performance Timeframe (i.e., perform within 12 months) that may be distinct from the Reporting Frequency (i.e., report 1 time only). If four or more measures are applicable for the practice, the provider must report at least 3 of them correctly for at least 80% of the cases (visits or patients). If 3 measures or less are applicable, the provider must report all of them correctly for at least 80% of the cases.

PQRI begins with services performed on July 1, 2007 thru December 31, 2007. Providers that report successfully are eligible for a 1.5% bonus subject to a cap. The bonus is calculated using total allowed charges for Medicare covered professional services furnished during the reporting period. All claims for services performed during these dates must be submitted to Medicare by February 29, 2008 to be considered. The bonus payment will be made next summer.

Providers wishing to participate in the PQRI need not register. All you do is begin reporting for services performed beginning July 1st. You must be a Medicare provider and use your individual NPI on your claims to be eligible to participate.

To find out more, visit the PQRI website.

CPT has some very specific rules for the use of modifier -59. This modifier is considered the modifier of last resort. You will typically use this modifier when no other modifier seems to fit.

Medicare and CPT have the same definition for this modifier. It is used for services that are not normally reported together but are appropriate under the circumstances. These circumstances may represent:

• different sessions or patient encounters
• different procedure or surgery
• different site or organ system
• separate incision or excision
• separate lesion
• separate injury
• services not normally encountered or performed on the same date by the same physician

-59 is an important modifier associated with the National Correct Coding Initiative (NCCI). This modifier is often used incorrectly with the NCCI edits. For NCCI, its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It is also appropriate to use this modifier when two procedure codes may not be reported at the same time except under special circumstances. It is inappropriate to use the -59 modifier to bypass the NCCI edits unless the special circumstance exists. The documented note should justify that the special circumstance exists and the criteria for this use of this modifier is met.

ICD-10 is out there. Did you know that we are the only country on the planet that has not converted to the ICD-10 system? ICD-10 has been trying to make its debut in our country for more than ten years now. Currently, the implementation date is set for October 1, 2009.

ICD-10 has over 200,000 diagnosis and procedure codes, ICD-9 has a little over 16,000. ICD-10 codes are all alpha-numeric codes while ICD-9 codes are numerical codes with the exception of V-codes and E-codes. ICD-10 will allow us to code to a much higher specificity and after all, that is the name of the game when it comes to coding our patient’s diagnoses for their insurance claims.

Providers and payers will need to completely redesign their business processes and systems to be able to handle this massive coding system. Although other countries have switched to ICD-10, no other country uses a version as complex as the US version.

There is a coalition of physicians, labs, and other providers and insurers that are urging Congress to push back the date. This group is urging for an implementation date of 2012 and here is why:

• Providers and payers will have to overhaul their business processes and systems. They will have to get their staffs educated and trained concerning the new ICD-10 system and their new software system to support it. This will be a costly venture. It is estimated that it could cost close to 14 billion dollars across the country.
• Physicians will not be able to rely on clearinghouses to translate their claims to a HIPAA compliant format before forwarding them on to the payers. ICD-9 codes cannot be translated to ICD-10 codes. There is no crosswalk as this is a completely different system.
• The current version of HIPAA transactions (4010) will not work with ICD-10. The industry will have to move to the newest version (5010). This is a major re-write and includes more than 850 individual changes. The ‘Workgroup on Electronic Data Interchange’ (WEDI) is concerned that upgrading to 5010 is too significant to be done in conjunction with ICD-10 implementation.
• Medicare is undergoing the largest contracting change in its history. They are transitioning more that 50 intermediary and carrier contracts to 15 Part A and B Medicare Administrative Contractors over the new few years. This requires transferring workloads from multiple contractors to a single entity, while at the same time integrating Part A and B claims processing systems and modernizing CMS information and accounting systems. This massive consolidation has the potential to cause major service problems for Medicare. Switching to ICD-10 so soon could further overwhelm Medicare and cause major backlog in claims processing and delayed payments to beneficiaries and providers, and increased opportunity for fraud. Medicare’s improper payments could soar.

The industry is hoping to begin the implementation date in 2009 after providers and payers have implemented version 5010 and Medicare contracting changes are finished. The providers and payers would then need 3 years to implement ICD-10 making the full implementation date 2012. It will be interesting to see what happens!

Codes recognized by Medicare are:

G0296 (new code): “PET imaging, full and partial ring PET scanner only, for restaging of previously treated thyroid cancer of follicular cell origin following negative I-131 whole body scan.” This one is covered for recurrent or residual thyroid cancer can’t be localized using the Iodine-131 whole body scan.

Q4078 (new code): “Supply of radiopharmaceutical diagnostic imaging agent, Ammonia N-13, per dose.” This one is used for the Ammonia N-13 when it is used as a tracer for PET scan for perfusion of the heart.

CMS already covers PET scans for diagnosing and for determining the status of the previously diagnosed patients with colorectal cancer, non small cell lung cancer, esophageal, lymphoma, melanoma, and head and neck cancer. Medicare also covers scans for solitary pulmonary nodules and refractory seizures.

CMS is considering PET coverage for other diagnosis such as detecting brain tumors, pancreatic cancer, cervical cancer, ovarian cancer, testicular cancer, and small cell lung cancer.

The Correct Coding Initiative version 7.3 that took effect October 1st has a total of 3,105 changes. 3,095 of these changes are comprehensive component edits and 10 are mutually exclusive code edits. The specialties most affected are anesthesiology, urology, and cardiovascular surgery.

In anesthesiology, the edits bundle many non-invasive monitoring procedures with anesthesia codes. Most of theses edits have the “0” indicator meaning a modifier will not override the edit.

The cardiovascular section has many new edits that have a “1” indicator meaning an appropriate modifier might override the edit. For example, cardiopulmonary bypass code 33031, 33020, 33251, 33261, 33305, and 33315 are comprehensive codes that include the component code of 35226 (repair of a blood vessel, other than fistula, lower extremity).

The urinary system includes multiple edits with a “0” modifier indicator. For example, transurethral resection of the prostate procedure codes includes manipulation procedures.

The male genital system has multiple comprehensive component edits. Many of these involve the cystourethroscopy procedures.

The nervous system also saw its share of edits, many of which have the “0” modifier indicator.

There are 10 new mutually exclusive code edits. Remember that mutually exclusive code edits involve codes that cannot be coded together. If they are, Medicare pays for the lesser of the two codes.

The Correct Coding Initiative is published four times a year. When the new version comes out each quarter, the old one is obsolete. This coding tool can be very helpful when coding for Medicare and other insurance carrier. This tool is a ‘must have’ for most offices.

Effective October 1, 2001, code 76977 for ultrasound bone density measurement will see about a 40% decrease in reimbursement for both the global and technical component when done in a physician’s office. This is due to a reduction in the Non-Facility Practice Expense RVU.

The globals for codes 11976, 15824, 15825, 15826, 15828, 15829, 15876, 15877, 15879, 17380, 33960, 36468, 36469, 41820, 41821, 41850, and 41870 have been set to 000 days. This means that an Evaluation and Management service provided on the same day usually isn’t payable.

Surgical codes 34800, 34802, 34804, 34808, 34812, 34813, 34820, 34825, 34826, 34830, 34831, 34832, 36870, 43231, 43232, 48554, and 48556 will be allowed co-surgeons of different specialties.

The bilateral payment of adjustment of 150% will not apply for bilateral surgery codes 73718 and 73719. Modifier –50 or listing the codes twice will not increase the reimbursement. Your reimbursement will be based on the fee for a single code.

Team surgeons will now be allowed for codes 48554 and 48556. Carriers will pay by report.

The standard multiple procedure adjustment (100% for the 1st procedure, 50% for the 2nd, 3rd, etc.) will now apply to code 17004 but not to 34826.

Effective January 1, 2002, two new modifiers will be recognized by Medicare.

• GY – item or service statutorily excluded or does not meet the definition of Medicare benefits.
• GZ – item or service expected to be denied as not reasonable and necessary.

The modifiers will replace the –GX modifier.

Modifier GY is for items and services never covered by Medicare such as routine physicals and cosmetic surgery. You are only billing the service with this modifier to get a denial. Carriers will be allowed to automatically deny services submitted with this modifier.

Modifier GZ is for items and services you expect to be denied due to medical necessity, such as a screening test done more frequently than allowed or a non-covered ICD-9 used. Only use this modifier if no ABN was obtained. Carriers will be allowed to automatically deny items and services with this modifier.

As before, use modifier GA when submitting a claim for a service considered not medically necessary and you have obtained an ABN. Carriers will still have to process these claims.