Pediatric Coding Alert

Modifier GA flags 99442 as patient's responsibilityAlleviating write-offs for noncovered, same-day E/Ms, phone care, screenings and vaccines might be as easy as A-B-N.That's an advance beneficiary notice (ABN), which is Medicare's version of a financial waiver. You have the patient's guardian sign the form at the time of service and collect the charge for a noncovered service. Sound simple? It is -- if you watch out for these pitfalls.Charge When Service Is 'Noncovered'You can charge a patient for a service only when the insurer considers the item noncovered. If the plan denies the service as bundled or covered in another service, you can't bill the patient for the denied item, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.Example: An insurer denies FluMist administration as noncovered due to Medicare's perception that patients self-administer intranasal sprays. You can charge the patient for the vaccine administration (for instance with 90467, Immunization administration younger than age 8 years [includes intranasal or oral routes of administration]; when the physician counsels the patient/family; first administration [single or combination vaccine/toxoid], per day).Be Up-Front About CostObtaining a financial waiver protects you if an insurer denies coverage of an item. "We use it for items that we know are not paid by all insurance companies, as well as a few items that we know certain insurance companies do not cover in our office," says Sharon Maylum, RN, clinical manager at NW Dayton Pediatrics in Ohio. For instance, "We use them for all 'behavioral' discussions" because due to mental health carve-outs, some insurers do not cover these in a pediatric office.The ABN alerts the patient that he may have to pay for an item "out of pocket," such as 99214 (Office or other outpatient visit for the E/M of an established patient ...) for physician behavioral counseling, for instance on thumb-sucking (307.9, Other and unspecified special symptoms or syndromes, not elsewhere classified). That way, the patient should not be shocked when his insurance denies coverage and he receives a bill from the pediatrician, Maylum says.Best practice: Give your patient an accurate cost estimate, which Medicare will require on its new form as of Sept. 1. That way, a patient can determine if she wants to have the service.Create Payer Form From CMS VersionYou can use a home-grown form for private payers, says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, in "ABN and Medical Necessity Essentials" presented by AudioEducator.com. Experts recommend using a version of the national standard form, CMS-R-131, which you can download from http://www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf. Substitute your insurance company for any mention of government insurance.Gone: If you heard that in lieu of an ABN you sometimes need to use a notice of [...]