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.

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.

Are you confused about the different types of nursing facilities? Medicare says the differences between the two are slight. The benefit seems to be the key here. Skilled nursing facilities (Place of Service code 31) patient stays are paid by Medicare Part A. Nursing facilities (POS code 32) patient stays are paid by Part B.

The June 4th correction to Medicare Carriers Manual transmittal 1690 allow codes 99301-13 to be billed with POS 31, skilled nursing facility; 32, nursing facility; 54, intermediate care facility; or 56, psychiatric residential treatment facility.

Remember that Medicare pays for the SNF under Part A for a stay of up to 100 consecutive days. The time starts over when a patient is discharged. So what do you do after the 100th day and the patient is still there? CMS says change the POS from 31 to 32.