Urology Coding Alert

Are you comfortable with the updated ABN?

CMS introduced a new ABN (advance beneficiary notice) form in June 2017 that you should be getting familiar with by now. But is your staff comfortable knowing when and how to use ABNs in the first place? Read on for the lowdown on the new form as well as a refresher on when it can come into play for urology practices.

The basics: You should file an ABN in advance of providing any services to a patient that Medicare might not cover. The process has been in place for years, but CMS announced an update to the ABN form CMS-131-R in March 2017, with implementation planned for June. The new form:

• includes language which informs beneficiaries about the no discrimination practices of CMS; and
• encourages beneficiaries to request an ABN in an alternate format if needed.

Key Point 1: Options Are Available

"The form has not really changed except to add closing language that informs patients CMS doesn't discriminate in its programs and activities and offers a website and phone number for beneficiaries to request the ABN in an alternate format, such as in large print type or a different language if desired," says Mike Granovsky, MD, FACEP, CPC, president of LogixHealth, a national coding and billing company in Bedford, Mass.

Because the ABN form is subject to approval by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (PRA), the notice is subject to public comment and re-approval every three years. During the 2016 PRA submission, the alternative format request language was added and the form reflects a new expiration date in the lower left corner of 03/2020 (Form Approved OMB No. 0938-0566).

For information on the new ABN, go to: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.

Key Point 2: Old Rules Still Apply

When you're filling out the new ABNs, be sure to keep these tried and true ABN guidelines in mind:

• Get ABN when Medicare might not pay:  "Anytime there's suspicion that Medicare may not cover a procedure that they ordinarily would, it's important to get an ABN when possible," explains Leslie Johnson, CPC, CSFAC, chief coding officer at PRN Advisors in Palm Coast, Florida.
• Explain service, and reason for no payment: In the ABN, there's a column where you should mention details of the service. Your provider will explain these details to the patient and also capture the reason why Medicare may not pay for the service. Your provider will typically use this form for Medicare patients and will typically explain the condition, diagnosis, or investigation that Medicare will not cover. "The explanation must be easy for the patient to understand and the form should be shared and explained prior to the service actually being provided," Granovsky says.
• Provide cost estimate: The provider, or "Notifier," should use appropriate language on the ABN form to explain a reasonable estimate for all of the non-covered items or services. Your provider should be able to give a good faith estimate based upon the frequency and duration of the service. CMS expects that the estimate should be within $100 or 25 percent of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. "Multiple items or services that are routinely grouped can be bundled into a single cost estimate," Granovsky says.
• Observe payer preferences: For patients who are not covered by Medicare, you should check with the payers for any ABN requirements. "Medicare Advantage or private payers may have their own ABN forms, so you should be aware of any updates from any payer with whom you contract," Granovsky warns.

Johnson agrees, saying ABNs are good practice "not just for Medicare, but actually, other payers are requesting similar [ABN-type documents]. It's a good habit for a practice to work into their routine, even if it seems difficult to obtain."

Key Point 3: Mind Your Modifiers

Providing the patient with an appropriately issued ABN isn't the end of your ABN work. Remember that Medicare also asks you to append the proper G modifier when submitting the claim.

Reasoning: Although the G modifiers are not required to garner payment for the services, experts agree it's a good idea to use the modifiers for compliance reasons. Additionally, the G modifiers also make things easier on the payers and the patients, as they indicate whether you will be able to request payment from the patient.

Here is a list of the G modifiers you might use on your ABN claims.

• GA (Waiver of liability statement issued as required by payer policy, individual case)
• GX (Notice of liability issued, voluntary under payer policy)
• 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)
• GZ (Item or service expected to be denied as not reasonable and necessary).