Wiki Medicare Reimbursement for Service for No CPT Code

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sstinch

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If you have a Medicare patient and you’re not sure the service is covered (there is no CPT code for the service), do you have to submit a claim with the unlisted CPT code and wait to get a denial or can you complete an ABN with a patient’s signature and bill the patient directly.

The concern is that the MAC could reimburse the unlisted but it would not be enough to cover the cost of services.

I always thought you had to submit to receive a denial but now I’m questioning myself.
 
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From what I've seen on here, you submit the unlisted CPT with a comparison CPT code for the similarity to the work that was done.
 
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Always have an ABN signed before a procedure or service that you believe may not be covered by Medicare and collect from the patient upfront. The unlisted codes are rarely paid. Then you can bill with a GZ modifier with a description of what was done in box 19.
 
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If the provider suspects that the service may not be covered, you can request that the patient sign the ABN and pay for the services in advance. However, per the instructions on the ABN form, the patient has the right to request that you do bill the services to Medicare. In the event that Medicare determines that the services are covered and makes payment to the provider, you would need to refund the amount of the overpayment back to the patient.

In other words, the purpose of the ABN form is to protect the provider in the event that a service is not a covered benefit. The form cannot be used by the provider to 'cover the cost of services', i.e. it cannot be used to force the patient to bear the costs in the event that the provider is concerned that Medicare's payment for a covered service will not be sufficient.
 
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CMS has a tutorial on ABNs: https://www.cms.gov/Outreach-and-Ed.../ABN-Tutorial/formCMSR131tutorial111915f.html

Think about what your question is. If you consider it closely I think you will see you answered it yourself. The A in ABN stands for ADVANCE. It means you can't sumbit a claim to see if it's denied and then decide later to issue an ABN, it has to be done before (in advance).
The provider can't balance bill the beneficiary just because the provider doesn't like the reimbursement amount from Medicare.

"50 - Advance Beneficiary Notice of Non-coverage (ABN) (Rev. 10862; Issued: 07-14-21; Effective: 10-14-21; Implementation: 10-14-21) A. General Statutory Authority - Applicability to Limitation on Liability (LOL) Section 1879 of the Act (where the LOL provisions are located) requires a healthcare provider or supplier (i.e. notifier) to notify a beneficiary in advance of furnishing an item or service when s/he believes that items or services will likely be denied by Medicare for any of the reasons specified in the statutory provision in order to shift financial liability to the beneficiary for the denial. For example, advance notice is required if the item or service may be denied as not reasonable and necessary under §1862(a)(1) of the Act or because the item or service constitutes custodial care under §1862(a)(9) of the Act. Notice (e.g., the ABN) is a way for healthcare providers or suppliers to establish beneficiary knowledge of non-coverage and therefore, shift financial liability for these items or services if Medicare denies the claim"

Regarding unlisted CPT: Your MAC has instructions on properly submitting claims with unlisted CPT. It requires PWK and explanation with documentation. Here is a Noridian example: https://med.noridianmedicare.com/we...rs-solutions/unlisted-procedure-and-noc-codes
 
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amyjph said:
CMS has a tutorial on ABNs: https://www.cms.gov/Outreach-and-Ed.../ABN-Tutorial/formCMSR131tutorial111915f.html

Think about what your question is. If you consider it closely I think you will see you answered it yourself. The A in ABN stands for ADVANCE. It means you can't sumbit a claim to see if it's denied and then decide later to issue an ABN, it has to be done before (in advance).
The provider can't balance bill the beneficiary just because the provider doesn't like the reimbursement amount from Medicare.

"50 - Advance Beneficiary Notice of Non-coverage (ABN) (Rev. 10862; Issued: 07-14-21; Effective: 10-14-21; Implementation: 10-14-21) A. General Statutory Authority - Applicability to Limitation on Liability (LOL) Section 1879 of the Act (where the LOL provisions are located) requires a healthcare provider or supplier (i.e. notifier) to notify a beneficiary in advance of furnishing an item or service when s/he believes that items or services will likely be denied by Medicare for any of the reasons specified in the statutory provision in order to shift financial liability to the beneficiary for the denial. For example, advance notice is required if the item or service may be denied as not reasonable and necessary under §1862(a)(1) of the Act or because the item or service constitutes custodial care under §1862(a)(9) of the Act. Notice (e.g., the ABN) is a way for healthcare providers or suppliers to establish beneficiary knowledge of non-coverage and therefore, shift financial liability for these items or services if Medicare denies the claim"

Regarding unlisted CPT: Your MAC has instructions on properly submitting claims with unlisted CPT. It requires PWK and explanation with documentation. Here is a Noridian example: https://med.noridianmedicare.com/we...rs-solutions/unlisted-procedure-and-noc-codes
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What is PWK please?
 
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