Wiki Charging Medicare patients for 20985 and 0054T

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I have orthopedic surgeons collecting 300-500 dollars from Medicare and commercial payer patients for 20985 and 0054T because they are non-covered services per Medicare. In reading the descriptions of the codes they are not reimbursed as separate procedures but as add on codes to surgical codes so are not payable. Therefore I would say no, we can not make the patient pay for this is the payer designates the codes as such. I am new with the practice and want to make sure we are doing this by the book. Anyone have any experience with this? Thanks
 
What I can tell you is that you have contracts with Medicare automatically (just by seeing Medicare patients) and I am sure you have contracts with most commercial payers. I would not bill the patient for anything that the insurance has not considered for benefits and put to the patient responsibility. Good way to lose your ability to see Medicare and Medicaid patients plus pay fines. For Medicare patients you would need to have an ABN signed -- before any treatment is performed -- letting the patient know that CMS will not make payment and the patient will pay for the services. From what little information you have here, none of it seems to be correct. I think you need to look into this before you get fined.
 
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No, they are not being charged if they don't have surgery. They are prepaying the navigation fee. They sign an ABN if they don't prepay. That wasn't my question. My question is, can they be charged if the payer deems the code non-covered.
 
No, they are not being charged if they don't have surgery. They are prepaying the navigation fee. They sign an ABN if they don't prepay. That wasn't my question. My question is, can they be charged if the payer deems the code non-covered.
This does not sound compliant to me. An ABN is for a procedure that the provider believes might be denied as medically unnecessary due to the diagnosis for which the procedure is being performed. (For example, an excision of a benign skin lesion may not meet the Medicare coverage requirements to support payment for the excision, so a provider may obtain an ABN and then the patient will be responsible if they choose to have the procedure anyway.) An ABN cannot be used to otherwise bypass Medicare payment rules. If a service is denied because it is considered bundled or incidental to another procedure, the provider cannot bill the patient for those, with or without an ABN.
 
As Thomas stated above, it all comes down to why the item or service is expected to be non-covered. If it is soley because the item or service is considered bundled or inclusive to the primary procedure, you can't shift the financial responsibility to the patient. If it's experimental/invesitgational I think you could. But again in this particular case you are talking about an add-on code and that may be considered inclusive. You would have to find out the LCD/MCD/coverage for the codes in question.


One of the reasons you must issue an ABN is when the Medicare item or service isn’t reasonable and necessary under Program standards, including care that’s:
  • Experimental and investigational or considered research only
  • Provider/supplier must issue an ABN to beneficiary prior to providing care that may not be covered by Medicare because it is not medically reasonable and necessary in a particular case
 
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