Orthopedic Coding Alert

When there's an issue with payment, ABN can be your friend.

Most practices providing services for Medicare patients have always been aware of the benefits of getting a signed advance beneficiary notice (ABN) on file before starting services that the payer might not cover. Now, all practices need to get on the ABN bandwagon ... and maybe not just for Medicare payers.

Explanation: Without a signed ABN on file, you might not be able to charge the patient for any portion of the service that Medicare might not pay for. Plus, more private payers are requiring ABN-type documents before certain procedures. And finally, practices that are in the habit of issuing ABNs can experience improved relationships with patients.

If you need help walking down the proper ABN path, check out these FAQs.

Q: When does the orthopedist need to get an ABN?

"Anytime there's suspicion that Medicare may not cover a procedure that they ordinarily would, it's important to get an ABN when possible," reports Leslie Johnson, CPC, coding consultant in Flagler Beach, Florida.

In terms of Medicare legality, "patients who are directly enrolled with Medicare are the only patients an ABN applies to. Those patients that are enrolled through a Medicare 'product' are not applicable to ABNs," explains Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC in Indianapolis, Indiana.

And as time passes, ABN-type documents are getting more common among private payers, Johnson says. "Actually, other payers are requesting similar [forms]. ... It's a good habit for a practice to work into their routine, even if it seems difficult," she says.

Q: What are some benefits of having a signed ABN before performing a service?

A: The main benefit is that you can bill the patient for any service, or portion of a service, that Medicare won't cover.

"The ABN acts a 'waiver or liability,' so to speak, by Medicare," explains Dillon.

Providers are required to give Medicare patients the ABN to sign, along with an explanation that Medicare might not cover, or consider medically necessary, the services the patient requests, Dillon says.

The benefits of ABNs don't end there, however. As important as an ABN might be for compliance, they might be even more vital in securing positive patient relations.

"There are some excellent benefits [to] an ABN. It builds up the trust that the patient has with the provider," Johnson explains "It shows a respect between the practice and the patient by stating what the cost will be and giving the patient the choice as to whether or not they wish to proceed without worrying about the bill that comes in later that they don't expect."

In this respect, ABNs place the provider and the patient in a win-win situation, says Johnson.

Patients might not like what they hear, but the ABN gives them the truth; and patients are more likely to "respect the truth and work with it. Patients are people, too," Johnson says. And when gauging the importance of ABNs, Johnson asks: "What is the value of mutual respect and trust between a patient and his/her provider?"

Q: Should the practice issue an ABN if it knows Medicare will deny a service?

A:  Dillon says yes. "Forwarding a Medicare patient an ABN form to sign prior to the service being rendered is beneficial for a modifier few reasons:

1. "It gives the patient notification that the service about to be rendered may be denied by Medicare and they may be ultimately financially responsible. If the patient knows they may incur charges, he/she may opt to deny the service or item.

2. "The ABN also gives the Medicare patient the right to appeal the decision by Medicare.

3. "A signed ABN gives the provider the legal right to bill a Medicare patient for the services that may be denied. Without this, the provider would have to write off services and/or items if denied by Medicare."