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Q: If a service is known to be noncovered because of the status indicator E-for instance CPT codes 78811, 78812 & 78813-would we issue an ABN to the patient? Or is there another form indicating non-coverage we should issue the patient?

Patient Financial Services Weekly Advisor, March 25, 2005

A: An Advance Beneficiary Notice (ABN) informs a beneficiary when an otherwise covered item or service may require an out of pocket payment. An ABN is not required if the item or services is never covered.

There is a form to advise beneficiaries of services Medicare never covers known as the "Notice of Exclusions From Medicare Benefits (NEMB)." Providing this form (CMS-20007) is currently optional. Providers may also develop their own notice.

You can view CMS' form by clicking here.

With that said, the descriptor for status indicator "E" is as follows: "Items, Codes, and Services not covered by Medicare based on Statutory Exclusion or for reasons other than Statutory Exclusion, not recognized by Medicare but for which an alternate code for the same item or service may be available, or for which Medicare does not provide separate payment. Not paid under OPPS."

Make sure that there are not alternate codes available for the services above.

Note: As of April 2005, codes 78811-78813 will be reimbursed under OPPS. There is no longer a need to use the alternate G codes. To read the transmittal, click here.

This question was answered by Diane Jepsky, RN, MHA, a healthcare consultant based in Seattle.

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