Pulmonology Coding Alert

Tip:  ABNs are your solution for payment on services Medicare won't cover

If you aren't obtaining advance beneficiary notices (ABNs) from patients who undergo treatments that Medicare may not deem medically necessary, your office could lose thousands of dollars each year. Follow this expert advice on getting a signed ABN, so you can collect payment directly from the patient. Here's What Makes an ABN So Important There are two main reasons you would want to obtain an ABN, says Stacie L. Buck, RHIA, LHRM, president and founder of Health Information Management Associates Inc. in North Palm Beach, Fla. "The first is to increase your revenue, and the second is to reduce your risk or the compliance implications associated with ABNs," she says.

If your pulmonologist recommends a treatment or procedure to a patient that Medicare may not cover, based on the reported indications, you should request that the patient sign an ABN. The document will help the patient decide whether he wants to proceed with the service even though he may have to pay for it, and, once signed, the ABN also ensures that your office will receive payment directly from the patient if Medicare won't pay on it.

Example: Your pulmonologist evaluates a return patient for his chronic obstructive bronchitis (491.20) and orders a complete blood count (85025, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count).

The pulmonologist's diagnosis of chronic obstructive bronchitis does not provide medical necessity for 85025. The physician would have to provide some other justification for the CBC, such as anemia (285.9). You should have the patient sign an ABN if the pulmonologist had no other medical necessity but insisted on obtaining the CBC. Don't Skip the Details Be sure the ABN clearly identifies the service/procedure the pulmonologist plans to provide, the estimated charge for the service, and why Medicare may not provide coverage. This way the patient knows exactly what he will be responsible for and why he can expect that his Medicare coverage won't apply to the procedure.

An ABN affects only those services/procedures you've specifically listed for a single encounter date. You should therefore list all services your physician thinks Medicare may deny. You should also include your reasoning for why you think Medicare may deny the service, such as details from Medicare's coverage plan or examples of similar claims that have been denied. Services your pulmonologist provides on a separate encounter date require a separate ABN. You're also prohibited from using blanket notices.

Tip: You'll want one copy of each signed ABN for your records and one copy for the patient.

Except under extremely rare circumstances, the physician should give the patient the ABN before performing the [...]