Urology Coding Alert

Learn the basics of this common document An advance beneficiary notice is a written notice that informs the beneficiary (that is, the patient) that Medicare might not cover a particular service or procedure. By signing the waiver, the patient acknowledges that he may have to pay for the procedure or service if Medicare does not. Why Won’t Medicare Pay? Medicare only allows for a finite number of certain procedures per patient per time period. For example, Medicare covers an ob-gyn physical including a pelvic exam every two years for low-risk women.

Also, there are some procedures that Medicare doesn’t cover -- namely routine physician checkups including the lab tests associated with the routine physical exam and elective procedures such as cosmetic surgery. In these cases, you won’t need a signed notification unless a secondary insurer is willing to pay.

Note: In these instances, a provider would use an NEMB (see below) rather than an ABN Medicare coverage varies from state to state and county to county, so be sure to check with your local carriers for guidance on covered procedures and ABN policies. Why an ABN? There are two main reasons to obtain a signed ABN from patients:

1. to ensure reimbursement for services provided but deemed not covered by Medicare, and

2. to reduce the risk of compliance implications associated with ABNs. ABNs help patients decide whether 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.

What Should an ABN Contain? A valid ABN must be Medicare-approved and must include:

1. Patient name and Medicare identification number

2. Name of items or services (prior to signature of patient)

3. Statement of provider’s belief that Medicare won’t cover the service

4. Statement of provider’s specific reason(s) for believing Medicare will deny the claim as procedure not reasonable or medically necessary (writing “medically unnecessary” is insufficient)

5. Patient’s mark of one of the two boxes on the mandatory Medicare ABN form indicating that he either wants to receive the items/services or not

6. Patient’s dated signature.

In addition, providers should -- but are not required to -- provide the patient with estimated costs of potentially noncovered items/services.

You should obtain a signed [...]