Wiki Medicare Denials


Thompsons Station, TN
Best answers
when medicare denys chiropractic codes for not medically necessary, can we will the customer as long as there is an ABN on file? And if so how do i find the cap price that we can charge the patient for that service?
If its a blanket ABN then no. ABN should state estimated patients liability is for the service so you cant just come up with an amount after the fact. Must be with $100 or 25% whichever is greater. The cost would be whatever your normal cost is.
Medicare has a written policy on ABN that must be followed. Such as you must read the ABN out loud to the patient, they must have the specific procedure indicated on the form and the reason for the ABN such as not medically necessary. As stated in the previous post you must also put in the Approximate cost for the procedure. And you must also use the GA modifier on the claim to indicate that the ABN has in fact been captured and signed. If you did not use this modifier when the claim was submitted, the patient will receive an EOB that indicates they are not to pay the provider.
It is a specific ABN for that procedure, and the GA modifier is attached to claim. I was told by another biller that you could only charge medicare patients a certain amount. Do you know about that?
Limiting Charge

Does this apply to only NON Par providers? MY question is if a patient's 98941 is denied due to not medically necessary and there is a specific abn on file stating that medicare may deny, can we charge the patient what our self pay rate is or does it have to be a certain percentage within what medicare normally pays for this code. Im so confused, any input will be helpful
Did you bill the adjustment code with a AT modifier? If you billed 98940 - 98942 with an AT they should cover it, but if it was 98943 they will not cover that.
Assuming you have a properly complete ABN, your fee (the cost to be paid by the patient), which must be detailed precisely on the ABN for the encounter at issue, is limited as follows: PAR providers - non-facility PAR rate for the level of CMT reported. Non-PAR Accepting Assignment (check comes to you), the non-facility non-par rate
for the level of CMT reported
. Non-Par Not Accepting assignment (check goes to patient) - the limiting fee
for the level of CMT reported
. You can access the Medicare fee schedule on the CMS website. Finally, even though the limiting fee rules of the Social Security Act (see 42 USC §1395w-4(g)) do not apply to statutorily non-covered services, some states impose limiting fee rules relative to Medicare beneficiaries that may be more restrictive. Check for those requirements as well.