Primary Care Coding Alert

Without ABNs, unpaid Medicare bills may become your problem

If you aren't obtaining advance beneficiary notices (ABNs) from patients who  undergo treatments that Medicare may not deem medically necessary, your office could have to pick up the tab on scads of uncovered or partially covered services.

"An ABN is a form that an office treating a Medicare patient has the patient sign if the office is unsure whether Medicare will pay for a certain service," says Kathryn Cianciolo, RHIA, CCS, CCS-P, a Waukesha, Wis., coding consultant for more than 20 years.

Cianciolo says that with the information provided on an ABN, the patient can make a more informed decision on whether he wants to have the procedure performed, given the fact that it's likely he will have to pay for it.

Example: Let's say a patient comes back to the office to see how she is responding to her blood pressure medication and to have a blood pressure check. You could bill 99211 (Office or outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, five minutes are spent performing or supervising these services), but you may run into "medical necessity" denials from certain Medicare local medical review policies (LMRPs). 

Before he performs the check, the physician should inform the patient that she may be responsible for the remainder of the bill if Medicare refuses payment. That's where an ABN comes in, says Cianciolo. When Do You Need an ABN?
 
Medicare accepts the general ABN form (also called the ABN-G) in all situations. In general, Cianciolo recommends obtaining ABNs each time a diagnostic procedure may not match up with the proper diagnosis code. If the patient has a diagnosis not listed on your LMRP for the procedure, but the physician still thinks the patient should have the procedure performed, you should get the patient to sign an ABN preprocedure.

Also, obtain ABNs when a patient is coming in for a screening procedure but the office is unsure if the procedure will violate Medicare's frequency-period rules.

"For example, Medicare will only cover an annual physical once every 365 days, or it will only cover a blood test or a mammogram every so many days," Cianciolo says.

Smart idea: "You definitely want to make sure you have an ABN if you are unsure about Medicare payment on any service," Cianciolo says.

Medicare does not mandate that you must use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless the doctor's office has a signed ABN on file.

"If you don't have an ABN and Medicare refuses the claim, you're pretty much out the money," she says. [...]