View Full Version : Is it just me? [long]

03-21-2007, 12:24 AM
One of the biggest headaches at my job is a concept known as Medicare limited coverage tests. For the non-US members, Medicare is a governmental supplementary insurance, mostly covering the elderly but also disabled persons. Medicare ALWAYS requires a diagnosis for ANY test ordered, and certain tests will only be paid for by Medicare if they are accompanied by certain diagnosis codes.

For the layman, let's say that you're on Medicare and you need a Hemoglobin A1C drawn, which is usually done for diabetics or those with a history of diabetes. Your doctor cannot submit a diagnosis of, say, chest pain. Well, he or she can, but that can't be the only diagnosis. There has to be a diagnosis that supports the test ordered. In other words, the diagnosis has to have some relation to the test.

Medicare requires that with these particular tests, if supportive diagnosis codes are not supplied, a form known as an Advance Beneficiary Notice (ABN) be signed and submitted. This form, as signed by the patient, acknowledges that he or she has been informed that his or her tests may not be covered by Medicare for X reason and he or she either YES, wants the test and understands that s/he may be liable for the costs, or NO, s/he doesn't want the tests performed. Note I said Medicare came up with this. This is not something we pulled from our nether regions just for funsies.

By calling clients and asking if there are any further diagnosis codes they'd like to submit, we're actually doing them a favor. It's one more safety net to catch that bill before it goes to Medicare and gets denied for insufficient diagnoses. However, the ABN must be filled out just so: YES or NO must be checked, tests must be checked or written on the form, and it must be dated and signed. And the tests checked must correspond with what was actually performed. If any of these conditions are not met, the ABN isn't valid. Simple, no?

No, apparently, it's not. I get completely blank ABNs (we supply clients with computers and our software in exchange for their using our lab services, and one of the features of this software is that it automatically generates ABNs for limited coverage tests). I get ABNs with no signature, or "Signature on File." I get ABNs with the wrong tests marked. I get no ABNs at all most often.

What makes this really frustrating is that we are not allowed to SAY that these are the "wrong" diagnosis codes, or even that they aren't supportive of the tests. All we can say is "do you have any further diagnosis codes?" You feel a bit like you're saying, "Warmer...warmer...now you're getting cold..." :doh:

Even worse is when the diagnosis is so patently obvious that they don't bother putting it down (such as performing a liver function panel to monitor long-term medication use), and then get annoyed at us and say, "You can't use ________?" (Well, I could if you'd put that on the req.)

Most of the time, people are pretty nice about it. But I only have an undergraduate degree and it's not in any healthcare-related field, and I get this concept. I'm frightened by how many healthcare professionals don't...but then again, I've spoken to registered nurses who didn't have the first clue what an ICD-9 was. :headdesk:

03-21-2007, 01:15 AM
Oh, god, Medicare. I can't stand dealing with Medicare.

I do ambulance billing for over 60 ambulance companies... Medicare requires not just diagnosis codes to pay for those transports, but medically necessary diagnosis codes (ie, you can't call because you stubbed your toe). The kicker? EMT's can't diagnose. They can only list symptoms because they are not doctors, and they don't have the equipment to diagnose, even if they were. Getting them to pay for services rendered is a big old pain...

As for ABN's...let's just say that your issue with them is apparently a very common issue. I can't get anyone to fill those out/sign them/do anything with them at all to save my life.

03-21-2007, 02:04 AM
A lot off topic, but are you guys working with SNOMED codes (http://www.snomed.org/) now? I'm currently working on pharmacy software in the UK that is slowly going over to them for NHS computerised re-imbursement and would like to know if it's as smooth as it looks if there's any major issues with it or is it just operational problems...

Geek King
03-21-2007, 01:49 PM
Yup, very common issue. I just had to waste an hour of meeting time listening to a corporate big wig talk to the billing office folks about getting those filled out properly by the offices my company bills for. I'm the local tech support, so I spent the time fighting off yawns. :rolleyes:

An hour for their stuff, and I get a one minute run on sentance that basically said, "You'll get the new equipment, but we can't tell you when."