Billing Medicare Patients for Services Which May Be Denied
Medicare patients may be billed for services that are clearly not covered. For example,
routine physicals or screening tests such as total cholesterol are not covered when there is
no indication that the test is medically necessary. However, when a Medicare carrier is
likely to deny payment because of medical necessity policy (either as stated in their written
Medical Review Policy or upon examination of individual claims) the patient must be
informed and consent to pay for the service before it is performed. Otherwise, the patient
has no obligation to pay for the test.
An Advance Beneficiary Notice (ABN), sometimes called a patient waiver form, is used to
document that the patient is aware that Medicare may not pay for a test or procedure and
has agreed to pay the provider in the event payment is denied. Each ABN must be specific
to the service provided and the reason that Medicare may not pay for the service. Blanket
waivers for all Medicare patients are not allowed.
Since both LMRPs as well as the new NCD for A1c include frequency limits, an ABN is
appropriate any time the possibility exists that the frequency of testing may be in excess of
stated policy. For example, if an A1c test may have been performed by another provider
less than three months ago for a patient with uncomplicated diabetes, it would be prudent
to obtain a signed ABN.
The CPT code modifier, -GA (Waiver of Liability Statement on File), is used to indicate that
the provider has notified the Medicare patient that the test performed may not be
reimbursed by Medicare and may be billed to the patient.
An ABN must: (1) be in writing; (2) be obtained prior to the beneficiary receiving the
service; (3) clearly identify the particular service; (4) state that the provider believes
Medicare is likely to deny payment for the service; (5) give the reason(s) that the provider
believes that Medicare is likely to deny payment for the specific service, and (6) include
the beneficiary’s signature and date. Routine notices to beneficiaries which do nothing
more than state that Medicare denial of payment is possible, or that the provider never
knows whether Medicare will pay for a service, are not considered acceptable evidence of
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...
Procedure code and description 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ele...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...
Coverage Indications, Limitations, and/or Medical Necessity This LCD describes conditions under which the coverage of nail avulsion/ex...
procedure code and description 93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOW...
Procedure code and description 95004 Percut Tests w/ Extrac Immed React # Allergy testing - Percut allergy skin tests - Percutaneous ...
Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, ...