Question Medical Necessity / ABN forms

Lynne77

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Duluth, GA
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Hello! Our provider did an I&D (10060) to treat a subaceous cyst (L72.3) on a patient who has Medicare. Per our provider, the cyst was not bothering the patient (ie, it's not painful or rubbing on clothing, etc) and she treated it at the patient's request because he didn't like the way it looks. Our provider feels this was cosmetic and that she can bill the patient a cosmetic fee. No ABN was signed. Per the LCD, this is a covered diagnosis for that procedure. When researching this issue, I found this on another professional website "Services that are not considered Medically Necessary are those that do not have a covered diagnosis code based on Local Coverage Determinations (LCD). One example is for excision of a lesion. If the lesion is being removed because the patient just doesn’t like how it looks, that is considered cosmetic surgery. If the lesion is showing some changes (i.e. bleeding, growing, changing color, etc), then it is considered medically necessary because it potentially can be malignant." My question is, if the lesion is not showing any changes but the diagnosis code is on the LCD, is the service cosmetic or should it be billed to insurance? And, if it is cosmetic, would we need an ABN? In my opinion, it needs to be billed; however, I would like to get some 2nd opinions on this. I work for a dermatology practice and this comes up a lot, especially for patients wanting moles removed for cosmetic reasons. Thanks in advance for your input!
 

Pathos

True Blue
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Location
Beaverton OR
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If there was no ABN signed, the provider cannot bill the patient separately. If CMS/Part C payer will deny the claim, then the provider is out of luck and should have had the patient complete the ABN prior to the procedure. It's unfortunate for the provider, but CMS is generally pretty firm on these types of cases.

Here is some readings:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-Form-Instructions.pdf
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html
 
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