In spite of what your patients want to believe, Medicare does not pay for everything, even care that beneficiaries or their doctors have good reason to think is necessary. You already know that there are many things for which Medicare has no payment, such as upgrading to a presbyopic or astigmatic intraocular lens during cataract surgery. For instance, things that are bundled have coverage but no separate payment. To help shed light on these issues, this month’s column deals with those things for which Medicare simply has no coverage. Of course, private payers and Medicare Part C plans (Medicare Advantage) may have different rules and coverage.

Q: What does it mean when we say that Medicare has no coverage for a service we deliver?
A: For the most part, this means that, due to the circumstances under which you provide a service, the patient has a financial responsibility to pay you.

Q: If Medicare has no coverage, what can I charge the patient?
A: Generally, you come up with your own charge, which is typically higher than what Medicare might allow.

Q: I have a patient who needs something and I’m not sure if it’s going to be covered. How can I find out what Medicare doesn’t cover?
A: There are a few sources you can turn to for that information: the Social Security Act; the Centers for Medicare & Medicaid Regulations and National Coverage Determinations (NCD); and your Medicare Administrative Contractor guidance and its Local Coverage Determinations (LCD) and Local Coverage Articles (LCA).

Q: What does the Social Security Act state regarding noncovered services?
A: The main noncovered things mentioned in the SSA (Title XVIII and Sections §1862(a)(7) and 1862(s)(8)) are:

• routine eye care;

• glasses (except for the one-time benefit after each cataract surgery);

• cosmetic services (surgery and those services directly related to it, such as drugs, etc.);

• refractive services (refractions and refractive surgery); and

• screening services (unless specially allowed by statute—glaucoma screening, for example, is a covered benefit although it’s rarely used).

Q: What does Medicare add to the SSA in terms of noncoverage?
A: Medicare amplifies the SSA through the use of CMS Rulings and Transmittals as well as National Coverage Determinations. The CMS rulings we are most familiar with are: NCD number 10.1, which notes that with routine cataract surgery, coverage includes one comprehensive eye exam, biometry and sometimes a B-scan if the cataract is dense, and all other things are not likely to be covered; NCD 80.8, which notes that endothelial cell count via specular microscopy is covered as part of the exam and not paid separately unless there’s corneal pathology present; and NCD 80.7, which indicates that refractive keratoplasty—such as LASIK, PRK or limbal/corneal relaxing incisions—is likewise not covered except in the rare case where the condition it’s being used to treat was surgically induced (e.g., post-trauma corneal repair). There are a few others, but most eye-care NCDs other than 10.1 noted above are in the “80” series. You can view the entire NCD list here: https://www.cms.gov/medicare-coverage-database/indexes/ncd-by-chapter-and-section-index.aspx.

Q: What about my Medicare Administrative Contractor? What does it have to help as a supplement to SSA and Medicare to confirm something is not covered?A: MACs write guidance in a number of ways. They all produce Local Coverage Determinations on a variety of services that note which CPT codes have coverage for various indications. They also may have a supplemental document to the LCD, such as Local Coverage Articles, that note which diagnosis codes have coverage. This use of multiple documents is a recent development.

Occasionally there is a link to a Billing and Coding Guide located at the bottom of the LCD or LCA. Of course, if the covered CPT code list in a LCD doesn’t comport with a covered diagnosis in the LCA, the service isn’t covered for that diagnosis. Many MACs have a Noncovered Services LCD which can help as well.

Q: What should we do if something is never covered and we want to explain that to our patients?
A: In this case, explain to the beneficiary that Medicare never covers what you believe he needs. Although the official Advance Beneficiary Notice of noncoverage isn’t required when something is never covered, to avoid “buyer’s remorse,” it’s a good idea to obtain proof that the beneficiary accepts financial responsibility for noncovered items and services. You can (and should) collect from the patient at the time of service since Medicare will never pay for that service. As noted above, the most common reasons for “never” coverage are that a service is done for screening, cosmetic or refractive purposes.

Q: What if something is covered by Medicare only for certain conditions, but my patient has none of them?
A: One example of this is blepharoplasty-—if it’s functional and meets special criteria for coverage, then Medicare will cover and pay, but it won’t cover/pay if the criteria in the LCD/LCA are not met. Another example is when you need a test result (e.g., topography) to discuss whether an astigmatic intraocular lens is appropriate; in this case the diagnosis is regular astigmatism, which is refractive, and the test is a patient-pay service.

In this case, you can think of the service you plan to do as a “sometimes-covered” service. In this situation Medicare notes that you must properly execute an ABN before you deliver the planned service(s). Fill out the form describing the planned service(s), note the specific reason why there’s no coverage, and your price for the service. Have the beneficiary sign, date and select their choice on the ABN form; keep the original for your files. It can be done on paper or electronically. If it’s done on paper, give the patient a copy. If you execute it electronically, you have to offer the patient the option of a paper copy.

Q: I have a patient who opted to change insurances before the date of surgery. What should I do?
A: First, verify the new insurance, as the rules may be very different for coverage/noncoverage. If it’s still noncovered but the patient now has Medicare Part C (a.k.a., Medicare Advantage, or MA), then a determination of benefits is required to identify beneficiary financial responsibility prior to performing the noncovered services. MA Plans have their own waiver processes and aren’t permitted to use the ABN form, so you might have to create a similar sort of financial waiver. Since the plans may not all have the same process, you should check with the plans.

Q: What about the ABN form itself? Is there anything else I should know?
A: Yes. You must always use the most recent version of the form. Use of an older version could mean the notice could be considered invalid and relieve the patient of the responsibility to pay you. 

The current form is due to expire at the end of March 2020 and Medicare hasn’t released the newest version of the form as of this writing. When the new form is out, be sure to collect all the older versions so that you don’t provide free services to patients unintentionally.  REVIEW