Billing Medicare for Non-Covered Services

by Cheri Freeman on September 4, 2009

Yesterday we discussed the practice of billing non-covered services under a payable code, and clearly established that such a practice would be considered fraudulent. This does not mean that the provider does not deserve to be paid for the service nor does it mean that he must automatically write the charges off as a loss.

By incorporating just two small steps as part of your front and back office routine, you can be reimbursed for the services rendered.

Front office:  Begin using the revised ABN (Advance Beneficiary Notice of Non-coverage) with patients who receive or may receive non-covered services. This form replaces the old  ABN-G and can also be used in place of the NEMB (Notice of Exclusion from Medicare Benefits) and gives the patient certain options to choose from in regards to receiving non-covered services.

A complete ABN packet in zipped format can be downloaded from CMS here: http://www.cms.hhs.gov/BNI/02_ABN.asp and detailed instructions on the proper use of the ABN can also be found in Chapter 30 of the Medicare Claims Processing Manual here:  http://www.cms.hhs.gov/BNI/Downloads/RevABNManualInstructions.pdf

Back office/billing:  Once it has been established that the patient has signed an ABN and has chosen to bill Medicare for the non-covered service, the non-covered service should be billed on the claim with the correct CPT code, any service type modifier required (as in the case of physical or occupational therapy a GP or GO), the GA modifier (to indicate a signed ABN is on file) and a GY (to indicate that this item is statutorily excluded or does not meet the definition of any Medicare benefit).

The end result will be that your regional Medicare contractor will process the claim and generate an EOB that allots the non-covered charges to patient responsibility.  You may now charge the patient for the service as indicated by the ABN, or if the patient has secondary coverage the charges may be covered and reimbursed by the secondary plan so that the patient has little to no out of pocket expense.

Now there are no surprises for the patient and he is given choices in the matter.  The provider gets paid for his services. No fraudulent activity has been engaged in.  That’s a win-win situation for all concerned.

Win-Win Situation

Win-Win Situation

Cheri Freeman, CMRS

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{ 2 comments… read them below or add one }

Lewis July 28, 2010 at 6:55 pm

How does this apply to a Medicare non-participating provider?

Cheri Freeman July 30, 2010 at 4:59 pm

Chapter 30 of the Medicare Claims Processing Manual, section 50 indicates that the requirements for use of the ABN form and patient refunds applies to both par and non-par providers.

http://www.cms.gov/manuals/downloads/clm104c30.pdf

Cheri Freeman, CMRS
Manager of Account Services
Virginia College Healthcare Reimbursement Services

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