You can't automatically assume that a procedure is eligible for reimbursement just because it's on the Centers for Medicare and Medicaid Services' (CMS) list of covered ASC procedures. CMS designates some procedures as Questionable Covered Services (QCS), which means that they are only covered when medically necessary. Examples include certain types of blepharoplasty, rhytidectomy, lipectomy, mammaplasty and abortion. Here are three ways to make sure you don't end up with unpleasant surprises when the time comes to collect reimbursement for these cases.

1. Research procedure coverage policies
CMS's Medicare coverage database at writeOutLink("www.cms.hhs.gov/coverage",1) contains three coverage documents that will guide you to the conditions under which QCSs will be approved for reimbursement: national coverage decisions (NCDs), national coverage analyses (NCAs) and local medical review policies (LMRPs).

The database is a work in progress. Medicare contractors still contribute previously unlisted LMRPs to the database; it will be several months before this phase of the project is done. Until the transition is complete, a full list of LMRPs is available at www.lmrp.net. This portion of the database will be updated on a monthly basis. The last, up-to-date version of a contractor's LMRPs will be available on each contractor's Web site.

Medicare contractors (fiscal intermediaries [FIs] and carriers) are also uploading coverage and coding articles to the database. Medicare contractors may make independent coverage decisions if an NCD or the Medicare Manual does not specifically address the item or service.

2. Mind your Ps and Q(CS)s
Medicare carriers process outpatient claims against national coverage policy edits from CMS. "Questionable Covered Service" is an edit that flags provider claims with CPT codes that describe procedures that are only covered by the Medicare program under certain medical circumstances. The carrier may also have LMRPs for some codes they consider a QCS. Medicare won't cover breast reconstruction for free flap (CPT code 19364) when performed for cosmetic reasons, but it will if performed as a follow-up to mastectomy.

3. Bill proactively.
Medicare carriers routinely suspend claims containing a QCS CPT code and request a copy of the operative report/ procedure note. If the documentation supports the medical necessity of the procedure, the claim will be paid. Otherwise, expect a denial. Two simple billing practices can speed up reimbursement turnaround and reduce the risk of the Medicare carrier denying your QCS claim.

First, submit these claims manually and attach a copy of the operative/procedure note. This lets the carrier review the claim immediately instead of suspending it and holding it up while you mail a copy of the operative note.

Secondly, send any additional supporting medical documentation along with the claim. For example, for eyelid reconstructive surgery, send photographs of the patient's eyelids.

If you give the carrier all the tools it needs to approve payment, you'll get paid quickly and in full for these "questionable" procedures.