Cardiology Coding Alert

CMS has unveiled its new advance beneficiary notice, and even though the hard deadline is several months away, you should take steps now to put it into practice.

Good news: The new ABN not only replaces the previous ABN-G (for physicians) but also incorporates the notice of exclusions from Medicare benefits (NEMB) form. CMS expects this new, combined form to "eliminate any widespread need for the NEMB in voluntary notification situations," according to the new ABN Form Instructions document.

The ABN's previous purpose: ABNs were previously only for procedures that Medicare might not cover and didn't apply to procedures that Medicare benefits statutorily excluded. You were able to use the NEMB for services that Medicare never covered such as cosmetic surgery or an annual well-woman examination (99381-99397, Preventive medicine services).

Now CMS will accept the new ABN form for either purpose, noting in its ABN Instructions that "the revised version of the ABN may also be used to provide voluntary notification of financial liability."

Don't worry: Although Medicare carriers began accepting the new ABN form as of March 3, CMS has implemented a six-month transition period. Therefore, you aren't required to use the new form until Sept. 1.

Although the ABN form has changed, many of the previous ABN "best practices" remain the same. Following is a quick look at three important ABN facts.

If Medicare does not consider a patient's upcoming procedure medically necessary, but the patient still wants you to perform the service, an ABN will let the patient know that he may be responsible for paying the non-covered portion.

ABNs help patients decide whether they want to proceed with a service even though they might have to pay for it. A signed ABN allows you to directly bill the patient if Medicare refuses to pay. Without a valid ABN, you cannot hold a Medicare patient responsible for the denied charges, says Kara Hawes, CPC-A, coder with Advanced Professional Billing in Tulsa, Okla. In other words, "The patient has to sign the ABN form at the time of service, otherwise the form is not valid," Hawes says. "When the claim is denied without an ABN, Medicare will not allow you to be reimbursed for the service or collect money from the patient."

ABNs help the patient understand her options. Once you have completed the ABN and discussed it with the patient, she can: 1) sign the ABN and assume financial responsibility for the procedure in question; 2) cancel the procedure; or 3) reschedule the procedure or service for a future date when she can afford it, or when Medicare may cover the procedure.

Catch this: "Medicare is going to require that the estimated cost be included on the form starting in September. That's a big change," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. You might as well adapt now and save risking mistakes later on.

When you expect Medicare to deny all or part of a service, you should append the correct modifier to the service code so Medicare's explanation of benefits (EOB) will properly outline when the patient has to pay. Use the following descriptions to guide your modifier choice.

You'll use modifier GA (Waiver of liability statement on file) when the service provider believes payers don't cover the service and the office has a signed ABN on file. This might include tests or procedures ordered without a payable diagnosis code or those ordered more frequently than covered, says Joan Adler with Adler Advisory Services in Atlanta.

Modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) applies when Medicare excludes the service and you're using the new ABN as you would have used the NEMB in the past.

Modifier GZ (Item or service expected to be denied as not reasonable and necessary) means that you didn't issue an ABN when you probably should have, and you cannot bill the patient when Medicare denies the service.

For instance, a physician performs an electrocardiogram on a patient with diabetes and no cardiopulmonary symptoms, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. The ECG (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) may be medically necessary to obtain information about the possible systemic effects diabetes may have on the heart, but Medicare won't pay for it.

The doctor needs to explain to the patient the advantages and disadvantages of the test and let the patient choose, Pohlig says.