Many practices assume that services without regular CPT codes are automatically non-covered and payable by the patient. That isn’t necessarily the case. What can you do about it?

Q. Aren’t Category III codes and miscellaneous codes non-covered?

A. While Category III codes (“T-codes”) and miscellaneous codes (codes ending in “99”) are not in the Medicare Physician Fee Schedule and do not usually have reimbursement values assigned, this doesn’t mean they are always non-covered.

Previously, Medicare Administrative Contractors (MACs) frequently had local coverage determination (LCD) policies that categorically identified these codes as non-covered unless there was a specific coverage policy. The 21st Century Cures Act of 2016 changed that. Since 2019, when the law went into effect, the LCD process changed. MACs are now prohibited from issuing a blanket non-coverage LCD and are required to consider coverage on a case-by-case basis.

Q. How are we supposed to know if a service is covered or not?

A. Some MACs have coverage policies for specific Category III and miscellaneous codes; check there first. In the absence of an LCD, establish a practice protocol. To do that:

• Determine coverage status
• Does a statute, regulation, NCD, LCD or article apply?
• Is the item or service “experimental or investigational”?
• Contact payer for prior authorization or predetermination
• Assess limitations of coverage (ICD-10 codes)
• Ambiguous coverage status usually requires a claim
• Don’t use fee schedule as a proxy for coverage
• Determine reasonable and defensible fee
• Use comparable procedures as a guide
• Consider time and resources
• Review current fees.

In many cases, the only way to know if a service is covered by Medicare is to submit a claim. In such a situation, keep in mind that:

• Absent an LCD, coverage is determined on a claim-by-claim basis
• Alternately, coverage follows LCD and associated article
• Articles list covered/non-covered ICD-10 codes
• A listed payment rate ($) is not de facto coverage
• An unlisted payment rate (n/a) does not mean noncovered.

Q. What if we decide non-coverage is likely and just decline to submit a claim?

A. Submitting a claim is not optional for either participating or non-participating physicians in most cases. You are required to file a claim unless you know for sure a service is not covered. For example, statutorily excluded services, like refraction, are exempt.

Beneficiaries may decline to have claims submitted, although that must be initiated by the patient and never suggested by the practice. The potential problem is that patients may change their minds and either submit a claim themselves or come back and require that you submit a claim. When that happens, you will probably be required to refund all or part of what the patient has paid.

There is the concept of “private contracting,” but it is limited to physicians who have opted out of the Medicare program altogether. This is a formal process that requires relinquishing the ability to be paid by Medicare for anything — this does not apply to most ophthalmologists.

Q. We can get an ABN though, correct?

A. Yes, although there are limitations here too. While payment for non-covered services is the beneficiary’s responsibility, Medicare Law (§1879, MCPM Chapter 30 §50.9B) contains a provision that waives liability if the beneficiary is not likely to know and did not have a reason to know the services would not be covered. If the beneficiary does not receive proper notice when required, s/he is relieved of liability. The provider is then responsible.

Problems with ABNs include:

• Unreadable, illegible, incomprehensible
• Beneficiary incapable of understanding it
• Given during an emergency
• Beneficiary coerced, misled, under duress
• Routinely given to all beneficiaries
• Notice given more than 1 year prior to furnishing service
• A mere statement of possibility that Medicare may not pay for an item or service
• Giving notice by telephone.

Q. What about Medicare Advantage patients?

A. First, remember that Medicare Advantage Organizations (MAOs) are not permitted to use the official ABN form. In a forceful memo from May 2014, CMS reminded MAOs that they are obliged to make pre-service determinations of benefits for each plan. Either patients or providers can request it — they should!

The bad news: There is no single form or process for all MAOs — each one does this a little differently. Check with the MAO plan for instructions.

Without notice of noncoverage prior to the service being provided, the Medicare beneficiary is not financially responsible. A refund may be due if the beneficiary made a payment without following this process.

Q. How about other payers?

A. Non-Medicare beneficiaries have limitations on coverage as well. Usually, these limitations are based on the beneficiary’s contract, either through their employer or an individual health plan. For these patients, you have more latitude in notification.

A beneficiary may not know that certain services are not covered by health insurance. Get a predetermination (prior authorization) when you can. When that is not possible, or just to cover the options, you can utilize a Notice of Exclusion from Healthplan Benefits form (tinyurl.com/4n34236v ). This tool clearly informs beneficiaries about coverage policies and financial responsibility to avoid misunderstandings later. Many practices make up their own forms for this purpose, loosely modeled on the Medicare ABN form. Customize it to fit your practice needs. OM

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .