# CPMA - ABN question



## arizona1 (Apr 4, 2011)

In the Medical Record Auditor, Deborah Grider book - ch 1 pg 17, last paragraph, Proper Notice

Can someone please help me understand this paragraph 

"If the determination is not favorable, the beneficiary has no appeal rights but may receive the service and have a claim submitted to the contractor. If the claim is denied, the beneficiary can pursue an appeal through the regular appeals process. A beneficiary who decides against the prior determination process but chooses to receive the service and seek coverage retains appeal rights."

I understand if services are not covered by Medicare the patient can still chose to have the service and then can submit a claim, then if the claim is rejected via medicare payment, can pursue payment through regular appeals process. Question: are they /can they only pursue through regular appeals process with other insurance (not Medicare) 

Secondly, I'm not sure of the last sentence, does this mean if beneficiary still chooses to have the services, they can look for coverage other than Medicare and this allows them to have appeal rights? I know I'm missing something here 

Thank you.


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## btadlock1 (Apr 4, 2011)

arizona1 said:


> In the Medical Record Auditor, Deborah Grider book - ch 1 pg 17, last paragraph, Proper Notice
> 
> Can someone please help me understand this paragraph
> 
> ...



"If the determination is not favorable, the beneficiary has no *appeal rights *but may receive the service and have a claim submitted to the contractor. If the claim is denied, the beneficiary can *pursue an appeal *through the regular appeals process. A beneficiary who decides against the prior determination process but chooses to receive the service and seek coverage retains appeal rights." I don't think "appeal rights" and the ability to "pursue an appeal through the regular appeal process" are quite the same thing, but I could be wrong. I think that once they learn that a procedure may not be covered, they can opt to have a pre-determination to see before getting the service. I believe that once they've been told that it won't be covered, they can't appeal the pre-determination. They can still appeal the *claim* denial on their own - it's their time to waste. 

Here's what you need to know about ABN's for the test:
What ABN stands for.
ABN's only apply to Medicare. Period.
ABN's can't be all-encompassing. You can't make patients sign a blanket ABN. They also can't be attached to anything else, like a notice of privacy practices.
Know the modifiers GX, GY, and GZ, and when to use them.
Know when you'd need to have one, and what happens if you can't/don't get one.
Read this: http://www.mayoclinic.org/becomingpat-jax/medicare-waiver-abn-faqs.html
I don't remember a whole lot of questions about ABN's, but I'm sure there were a few. They probably didn't make much of an impression on me because the questions weren't as hard as other areas of the test - I either knew the answer, or could figure it out through the process of elimination.

I *strongly* suggest shift your worry/focus to RAC audits, RAT-STATS, Corporate Integrity Agreements, Business Associates, and anything with "OIG" on the page. Those topics* DID *make an impression on me.  

If you come across a lot of confusing things in the book, know that it's not just *you*...I found *all kinds *of problems with the book that were _extremely_ confusing - typos, contradictory statements, etc.  - Just a complete lack of proofreading. I have a funny story about how I handled it, but that's best left for another day! 

Good luck!


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## arizona1 (Apr 4, 2011)

Thank you so much! Yes, it is very frustrating trying to study from a book of double talk and errors. Not to mention I found differences between the NAMAS and the Deborah Grider books. 

Thanks again for your help!


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## twizzle (Apr 4, 2011)

*CPMA test*

I too find 'Medical Record Auditor' ambiguous, inaccurate in places, and full of typos. I then bought the NAMAS guide following recommendation from a CPMA (which is not on the AAPC recommended study list for the test, but which is an AAPC book)..... all rather confusing. The NAMAS guide is better I think but is ridiculously expensive and still has plenty of typos (and some errors) to negotiate.
Brandi, I'd love to learn how you handled the contradictions and proof-reading errors; they irritate me to the point of distraction.


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## btadlock1 (Apr 4, 2011)

*It's a bit of a long story...*



wassock said:


> I too find 'Medical Record Auditor' ambiguous, inaccurate in places, and full of typos. I then bought the NAMAS guide following recommendation from a CPMA (which is not on the AAPC recommended study list for the test, but which is an AAPC book)..... all rather confusing. The NAMAS guide is better I think but is ridiculously expensive and still has plenty of typos (and some errors) to negotiate.
> Brandi, I'd love to learn how you handled the contradictions and proof-reading errors; they irritate me to the point of distraction.



A little bit of background: I had virtually no auditing experience (or even coding, really - I just did claims follow-up for 3 years); I couldn't afford the conference, and I'm one of the only people in my area with a CPMA certification - even now (and I got mine in October), I didn't really use the forums then, either, so I couldn't get anyone to help me figure out why I was getting the wrong answers on my E/M audits. (I was getting hung up on the exam, as usual, and I wasn't very good at the History yet, either. Oddly enough, I got the MDM right every time. I couldn't figure out where my mistakes were, because there was no rationale for the answers in the book. They just were what they were, and most of the time, I was off by one level.

I got all the way to the end of the E/M, and was working on the practice audit cases, and was getting really frustrated, because I couldn't tell if I was really just not understanding the material correctly, or if there were errors in the answer key. I decided I'd had enough, when I got to one E/M that I came up with 99205, and the answer key said 99202. After getting some practice and feedback from others, I understand it now, but at the time, I just did _not_ get what I was doing wrong. 

In October, I only had a CPC-A, because my boss hadn't given me a letter on company letterhead, saying I'd been working there for 3 years, so I could get the "A" off of my CPC. I think that it had a major affect on the way I was treated...I emailed the AAPC, at my wit's end, desperately asking for someone to look into the errors in the book, and explain to me how they came up with the answer to that audit case. I figured I'd given too much credit in the History or Exam somewhere, but couldn't figure out where. I gave examples with specific page #'s, of major errors  - I wasn't trying to be tacky - I just wanted it to be easy for whoever read the email to know what I was talking about. I made my desperate plea for help, and didn't expect to get a response - I had the 2nd Edition of the book, and they'd just released the 3rd one, so I figured I'd be blown off. I've actually still got the emails, so I'll just paste them into here so you can see what happened, and judge for yourself. When I sent the first email, I was frustrated. When I sent the reply, I was mad. I attached copies of the pages I had found errors on, and circled the errors, along with anything else I referenced. 



> To Whom It May Concern:
> 
> I'm not sure who I should really be contacting about this, but I have a few questions regarding the CPMA Exam, and over the information in the textbook, Medical Record Auditor, 2nd Edition. I apologize if this note seems more like a complaint than an inquiry; I've reached the point that I'm frustrated and anxious about whether I'll be prepared to pass my exam in 2 weeks.
> I've been studying to take the CPMA exam on my own, since I can't locate anyone offering a preparation course, except for the AAPC's 2-day, $700 seminar in Dallas, which I can't even afford to travel to, much less, attend. I've worked as a commercial insurance specialist for a physician practice management group, following up on outstanding and denied claims for over 150 providers of various specialties, for nearly 3 years. I've appealed countless denials successfully, based on coding guidelines, payer policies, and HIPAA regulations, and have gained a wealth of knowledge on those subjects. I review medical records on a daily basis to determine whether or not claims were coded correctly, whether or not medical necessity has been established for many procedures, and to verify that our claims are consistent with the documentation. When I read about being a medical record auditor, it seemed like something that I would enjoy doing, so I decided to become certified so that I could someday steer my career in that direction. I've followed the suggestions on the AAPC's website to prepare on my own, to the letter. That included purchasing the Medical Record Auditor, 2nd Edition, as a tutorial guide. At the time that I bought the book, about 3 months ago, there was no mention of a 3rd edition's impending release, otherwise I would have waited to get more updated material.
> ...





> Brandi:
> 
> First of all there is a 3rd edition that has been updated for Medical Record Auditor.  I suggest that you purchase that edition which will have all updated information.  I believe you are confused and I do recommend you take a course.  You are a CPC-A and that tells me you do not have the industry experience necessary to successfully pass the CPMA examination without an instructor to explain auditing to you which is different than coding. I am not finding the errors you are finding.  If you are having trouble selecting your levels for E/M it is most likely the MDM.  Determining the overall level is more than identifying key components, it should also include medical necessity.  If the provider has a 99205 documented with the key components, it doesn’t necessarily make it a level 5 visit if medical necessity does not support it.
> 
> ...





> Deborah,
> 
> I appreciate you taking the time to respond to me; however I find the condescending and dismissive nature of your reply insulting, and unhelpful. As I mentioned before, I would have _happily _purchased the 3rd edition of your book, had I been aware that it was due to be released soon after I bought the 2nd edition, but there was *no mention *of it on the AAPC's website anywhere.
> 
> ...



I never got a reply. This all went down on October 11th; I was so furious, that I studied 10 times harder, just to prove her wrong. I honestly don't think she even read my first email; her reply certainly didn't show it, if she did. It seemed like she saw the CPC-A, and then skimmed the message, picked out a few key words, and spit out a reply as quickly as possible (perhaps she thought I was wasting her time with elementary questions...who knows.) Anyways, in the end, I passed the test the first time, and found out on October 29th - it was *awesome*, but even more so, because I knew that at least one person was counting on me to fail. I had to send her one more message:



> I just thought you might be interested to know that I did pass the exam on my first attempt. Thanks!
> 
> Brandi Tadlock, CPC, CPMA



Keep on truckin', ladies! If you're here asking questions, you're already a step ahead of where I was!


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## twizzle (Apr 4, 2011)

*Long story...*

Brandi. What a great story and more power to you for following your instincts and standing up for what you thought was right. How can recommended study material be so wrong? I'd love to be a proof reader for any kind of medical book/journal or whatever because I know I can do a far better job than most of these people. It's a shame your query was treated in such a dismissive way but there was only one winner.
Anyway, power to you ladies ( I'm a guy but I back you all the way... why wouldn't I, you were right?)


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## btadlock1 (Apr 4, 2011)

wassock said:


> Brandi. What a great story and more power to you for following your instincts and standing up for what you thought was right. How can recommended study material be so wrong? I'd love to be a proof reader for any kind of medical book/journal or whatever because I know I can do a far better job than most of these people. It's a shame your query was treated in such a dismissive way but there was only one winner.
> Anyway, power to you ladies ( I'm a guy but I back you all the way... why wouldn't I, you were right?)



Sorry! I wasn't trying to emasculate you, there! I don't know if the AAPC has someone who proofreads those before publication, but they should really get someone if they don't. It's a widespread problem (I also saw it with the CPC curriculum, which is a big part of the reason I didn't spend the money for the CPC-P guide.) Personally, I would have taken offense to the fact that* there were errors *in a book that had my name on it, and I probably *wouldn't* have been defensive with someone for bringing it to my attention. I think I'd be upset that I put a lot of time and effort into creating something that ended up looking sloppy and carelessly thrown together, because nobody bothered to _read_ it before printing and selling it. (Or because no one thought I was capable of making a mistake; therefore no one checked my work.) But, then again, I take a_ lot _of pride in my work and* it is *a big deal to me if my name is associated with a crappy job.

I'd gotten over my anger with the situation long ago, but I kept the emails because even though it was 'negative', that experience was the biggest motivator I've had in a long time, and it reminds me that other people don't know my potential, so if I listen to others instead of trusting my abilities, I might never reach the level of success that I'm capable of reaching. (as corny and cliche as it is, it's just a reminder of how things work out when you "believe in yourself".) And really, that's my whole point in posting it on here, too. That, and I think it's kind of funny.

I'm with you, though - if they ever do get on the ball and hire some real editors, I'll gladly offer up my critiquing-services!


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## losborn (May 10, 2011)

I just came upon this story - you are absolutely right!  The book is FULL of errors that made it all the more confusing to study!  And I had the same problem that AAPC never mentioned the new one was coming out; I felt ripped off.  It also makes me wonder if anyone has purchased the 3rd edition and if there are substantial correction/changes in it.

AAPC has ventured into the Auditing field, and now I see they are also offering a compliance certificate.  I was lucky that where I live a CPC still carried some weight.  Collegues in other parts of the country need to have a CSS, which is more and more in demand here as well.   I think AAPC should concentrate on its core membership needs, rather than branching out again.    It makes me think they are actually diluting their influence by spreading too thin.

Anyway - my two cents!

Lin
CPC, CEMC, CPMA


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