Pulmonology Coding Alert

If youre about to perform a procedure that your carrier may not consider medically necessary, you must obtain a signed advance beneficiary notice (ABN) from your patient beforehand. You then submit the bill with the appropriate code, and if its refused, you can collect from the patient.

According to the Medicare Carriers Manual, an ABN allows a beneficiary to make an informed consumer decision by knowing in advance that he or she may have to pay out-of-pocket.

The Office of the Inspector General (OIG) for the Department of Health and Human Services (HHS) has released its work plan for fiscal year 2001. It states, Indications are that practices vary widely regarding when ABNs are provided, especially with respect to noncovered laboratory services.

Not Medically Necessary or Not Covered?

If the procedure in question is not covered by Medicare or your carrier, theres no need for an ABN. It wont be reimbursed, regardless of the diagnosis. If a test is considered routine screening, for example, it wont be paid. Although an ABN isnt required before you can bill the patient for the service, you should inform the patient that he or she will be responsible for payment.

But there are gray areas in the question of medical necessity. Some procedures may be medically necessary for one patient and not for another.

Quin Buechner, CPC, MS, M.Div., coding consultant, ProActive Consultants, Cumberland, Wis., says, Medical necessity is defined by the insurance carrier from a payment perspective. Good medicine may not always be the same thing as paid-for medicine. Coders must know what the carriers think is medically necessary. When Medicare doesnt think its medically necessary, an ABN is essential.

Buechner points out, for example, that a spirometry (94010, spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) is never covered if its taken for a baseline. A healthy baseline may be good medicine, but it wont pay.

Another example is 94150 (vital capacity, total [separate procedure]). Again, if its just for a healthy baseline, it wont be covered. The diagnosis makes the difference between payment and denial. Also, there are areas in which the physician and the carrier may differ. Buechner says, A physician may believe he or she has a rational diagnosis, which is a good reason to order the test. But the carrier may disagree and rule that the diagnosis doesnt justify the test.

Coders should also know how many visits per month their carrier will pay for. The physician may believe the patient needs more than the carrier will cover. Buechner advises, Give your billing staff enough time to take a good look at what the carrier accepts. [...]