Find out before you deliver the service.

Some payers have now made it harder to figure out whether a service has coverage. Sometimes we know things our office does will be covered by the patients’ insurances. Cataract surgery is most likely covered, for example, if properly documented. The payer has a published policy, we follow it, and payment comes in as expected.

Unfortunately, it is becoming much more difficult to determine noncoverage than it used to be. MACs no longer have Local Coverage Determinations for noncovered services. These were the policies that listed the codes with no coverage (or payment) so you could rely on that and notify patients accordingly. You knew where you stood.

Now, in some cases, there may be no guidance at all. What then?

Don’t assume coverage

First, it needs to be understood that medical payers do not generally pay for nonmedical services (refraction or refractive services, for example). In some cases, a code is covered but not for all diagnoses. Since not all payers cover the same things in the same way, even having a medically oriented code may not be enough when no policy exists.

Consider financial waivers

Payers generally recognize the more common Category I CPT codes, so reimbursement is usually obtainable and we don’t worry. If there was doubt in the past, you would have gone to the published “Noncovered Services” policy and verified that no coverage exists and have the appropriate discussion about patient pay. Payers may change over time (from covered to noncovered or vice versa).

A recent example of this is the eyelid treatment known as LipiFlow (J&J Vision). It used to be quite clear there was never coverage for this Category III code (0207T); it appeared in the policies referenced, patients were charged directly, no claims were required. Recently, some areas of the country are now seeing coverage, so noncoverage in your area may no longer be guaranteed.

To protect your practice and the beneficiary, you may need to handle this service differently by using a financial waiver (for Medicare Part B, the Advance Beneficiary Notice of Noncoverage, or ABN, is that document). If coverage is there and payment comes in, you might have to accept it.

Beware of unlisted and nonspecific codes

I’ve recently heard that some providers or billers want to code via an unlisted code to guarantee they can still collect from the patient. CPT contains lots of unlisted or nonspecific Category I codes; they end in “99” and are defined by the anatomy affected (for example, there is unlisted procedure, eyelid (67999) and unlisted procedure, conjunctiva (68399).

In selecting a procedure code, CPT books have long instructed the following: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.” The payer might provide coverage since the underlying medical condition has coverage and the particular treatment method codes as unlisted.

There are also Category III codes; they are temporary, but even they might have coverage and/or payment. At least most MACs have a “Category III policy” that may list the coverage status. Arriving at a code — even an unlisted one — does not imply either coverage or noncoverage; do not guess as you could run afoul of insurance participation rules — which is a big deal. For covered unlisted codes, the payer decides on the payment for the service and the claims process is prolonged considerably.

Sometimes payment may be exceptionally low, so be sure and check that in advance too. You don’t want to do something for less than its costs, but you likely cannot deny continued service once a therapy begins without a good reason.

Understand Part C and private pay differences

Lastly, for Medicare Part C and private payers, coverage, payment, and forms/processes may be different. You might even have to ask the payer each time even if something is already published as noncovered.

Check each payer

No one prefers to use financial waivers, but they will unfortunately become more common than in the past — albeit not on everything. Payers can change their decisions over time, so without a recent coverage and payment decision or policy, the only way to know each time is to use a financial waiver, file claims, and then wait for claims adjudication. Check each payer periodically.

An important piece of this is determining the potential payment. If no therapy has been initiated and payment might cause the practice to lose money, you might be able to refer the patient elsewhere, but important contractual and ethical considerations come into play.

As always, “good coding to you.” OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.