- The Primary Diagnosis will be the reason for the visit that day.
- If only signs or symptoms are known, code those. If by the end of the visit a definitive diagnosis is known, that becomes the Primary Diagnosis.
- Code all other conditions affecting treatment of the patient.
Diagnostics and Procedures
- For Medicare, all diagnostic tests and procedures require medical necessity. The diagnosis code(s) or description of the problem(s) must be documented on the order. There are codes for screening, follow-up, pre-procedure evaluation, etc.
- If the test is to rule out a condition, list the symptoms necessitating the test and then the condition to rule out.
Advance Beneficiary Notice of Noncoverage (ABN)
- The Financial Liability Protection provisions (FLP) of the Social Security Act (the Act) protects beneficiaries, and health care providers (physicians, practitioners, and suppliers) under certain circumstances, from unexpected liability for charges associated with claims that Medicare does not pay.
- If a provider wishes to order a test that is not covered by Medicare, an ABN must be given to the patient prior to the test.
- Notifiers must explain, in beneficiary friendly language, why they believe the items or services described in Blank (D) may not be covered by Medicare. Three commonly used reasons for noncoverage are:
- "Medicare does not pay for this test for your condition."
- "Medicare does not pay for this test as often as this (denied as too frequent)."
- "Medicare does not pay for experimental or research use tests."
- Excluded items would include, but not limited to the following items:
- Long term care benefits;
- Routine dental care;
- Eye examinations, refractions and eyeglasses;
- Foot care (routine);
- Screening Laboratory tests except those under preventative services;
- Cosmetic Surgery;
- Orthopedic Shoes;
- Routine physical exams (except the one time "Welcome To Medicare Physical";
- Hearing Aids and exams for fitting hearing aids;
- Prescription Drugs (except for Part D);
- Travel (health care traveling outside the US).
- The modifier GA is applied to the test code to show that the provider has provided an Advance Beneficiary Notice (ABN) to the patient.
- Modifier GX has been created (effective April 1, 2010) and has a definition of "Notice of Liability Issued, Voluntary Under Payer (CMS) Policy."
- Used to report when a voluntary ABN was issued for a service which is excluded or does not have a benefit category by statute.GX modifier may be reported on the same line as certain other liability - related modifiers.
- Must be submitted with non-covered charges only.
- Will be denied by the Medicare contractor as a beneficiary liability.
National and Local Coverage Determinations
Many Medicare tests, diagnostics, and procedures are only covered under certain conditions. These are described in either a National Coverage Determination (NCD), or a Local Coverage Determination (LCD) for our particular region. A search can be done for a test or procedure on the CMS Website.
Enter either the code or description for the coverage in question and select the Northern California region. Any national or local determinations will appear. There will be an explanation about the determination and a list of the diagnosis code and/or other conditions for coverage. If there are no results for the search, there are no determinations for that test or procedure.