Wiki How to complete ABN for Medicare

[tlwhlw]

I've been reviewing CMS website for the new ABN forms. I need a little help for the "Reasons Medicare May Not Pay" section. In the past, we have used this reason:

"Medicare does not cover this procedure as is may not be a medically necessary diagnosis."

CMS gives these as commonly used reasons:
"Medicare does not pay for this test for your conditon."
"Medicare does not pay for this test as often as this (denied as too frequent)."
"Medicare does not pay for experimental or research use tests."

Our statement does not seem to fit in any of these reasons. I have been searching the CMS website for anything else, but no luck. Any thoughts on where to look further? Would our statement still be correct to use? Thank you for your help!

Tracy L. Wood, CPC

 

[jenny king]

You must be specific as to why Medicare will not pay. Most of the time it is a matter of a limited number of services per a specified time period (which the patient never knows if they have had) or diagnosis specific coverage. Here are a couple of examples that we use. We use ABNs for Bone Density Tests. For the reason we have "Medicare will only pay for bone density test every two years". We also use ABNs for Trigger Point Injections. For these we have "Medicare only pays for trigger point injections for specific diagnosis. Your diagnosis is not one of the diagnosis that Medicare as approved for coverage of this procedure". Hope this is helpful.

 

[nelsong5]

Medicare has established rules as to what diagnosis covers what procedures/test.

I would suggest you review them before submitting a claim that would not be covered because you will receive a remittance advice of CO-11 which means the diagnosis does not cover the service/procedure and you would negate the effect of having such a denial on the patient.

What may happen if you find the appropriate diagnosis with the appropriate procedures is that they may deny due to no medical necessity.

If that is the case i would put in the ABN the following:

"Medicare does not cover this procedure because the procedure/service may not be medically necessary"

This is different type of denial, the remittance advice would be CO-50.

Hope this helps.

 

[mitchellde]

In a presentation from Medicare a few examples were given of acceptable vs not acceptable reasons for section E:
Acceptable:
“The patient does not have the required diagnosis 327.23 to qualify for this item per LCD 171.”

The patient currently has a standard wheelchair (K0002) paid for by Medicare on 12/2/2009 which is same or similar to this power wheelchair (K0823).”

Unacceptable:
“Patient might have similar equipment on file.”

“Medicare may not pay for this item.”

“Patient may not be eligible for Medicare Part B at this time.”

“Not enough supporting documentation in the medical record.”

Maybe this will assist you.

 

[nabernhardt]

I had a question relating to ABNs also. If its ok how are other facilities handling where a patient is drawn in our clinic and then the specimen is processed in our Lab at the hospital where then Medical Necessity is checked. The patient is already gone. And the diagnosis for that test is not meeting medical necessity.