Oncology & Hematology Coding Alert

Question: I-ve read that there's a new ABN form, but I can't find it anywhere. Where should I look?

South Carolina Subscriber

Answer: There are actually two versions of an advance beneficiary notice (ABN) form now, and they are available in English and Spanish. You can find all of them by going online to http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp and looking under "Downloads."

Which is which? The Advance Beneficiary Notice -- General Use (ABN-G) is for "providers, physicians, practitioners and suppliers for all situations where Medicare payment is expected to be denied including laboratory tests," Medicare says. "The Advance Beneficiary Notice -- Laboratory Use (ABN-L) is specifically for use when only laboratory services are being delivered."

There are two main reasons to obtain a signed ABN from patients:

- to ensure reimbursement for services provided but deemed not "medically necessary" by Medicare

- to reduce the risk of compliance implications associated with ABNs.

ABNs help patients decide if they want to proceed with a service even though they might have to pay for it. A signed ABN ensures that the physician will receive payment directly from the patient if Medicare refuses to pay.

Without a valid ABN, you cannot hold a Medicare patient responsible for the denied charges, leaving the bill in the physician's lap.

Tip: After the patient has signed the ABN, you must inform Medicare by appending modifier GA (Waiver of liability statement on file) to the CPT code describing the (suspected) noncovered service or procedure.

When Medicare sees modifier GA, it will send an explanation of benefits to the patient confirming that he is responsible for payment. If you don't append modifier GA, Medicare will not inform the patient of his payment responsibility.

Hidden trap: Don't make each patient sign an ABN just in case. "Blanket" ABNs are forbidden by Medicare. The physician can only have the patient sign an ABN if there is a valid reason to suspect that Medicare will not pay.