Cardiology Coding Alert

ABNs are required before billing a patient the remainder of a Medicare bill If you aren't obtaining advance beneficiary notices (ABNs) from patients who undergo treatments that Medicare may not deem medically necessary, your office could end up picking up the tab on scads of uncovered or partially covered services.

"An ABN is a form that an office treating a Medicare patient has the patient sign if the office is unsure whether Medicare will pay for a certain service," says Kathryn Cianciolo, RHIA, CCS, CCS-P, a coding consultant for more than 20 years from Waukesha, Wis.

Cianciolo says that with the information provided on an ABN, the patient can make a more informed decision on whether he wants to have the procedure performed, since  it's likely he will have to pay for it.

Example: You should report 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) for the stress portion of a nuclear stress test to assess myocardial function. However, some Medicare carriers require a primary and secondary diagnosis for 93015. If your only diagnosis for the patient is chest pain (786.50), the claim may be denied for lack of medical necessity.

Before he performs the test, the cardiologist should inform the patient that he may be responsible for the remainder of the bill if Medicare refuses payment. That's where an ABN comes in, Cianciolo says. When Do You Need an ABN? In general, Cianciolo recommends obtaining ABNs each time a diagnostic procedure may not match up with the proper diagnosis code. If the patient has a diagnosis not listed on your local medical review policy (LMRP) for the procedure, but the cardiologist still thinks the patient should have the procedure performed, you should get the patient to sign an ABN preprocedure.

Also, obtain ABNs when a patient is coming in for a screening procedure but the office is unsure if the procedure will violate Medicare's frequency-period rules.

"For example, Medicare will only cover an annual physical once every 365 days, or it will only cover a blood test or a mammogram every so many days," Cianciolo says. If the doctor sees reason for another screening procedure before Medicare allows you to bill for the procedure again, get an ABN on file.

Smart idea: "You definitely want to make sure you have an ABN if you are unsure about Medicare payment on any service," Cianciolo says.

Medicare does not mandate that you must use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless the doctor's office has a signed ABN.

"If you don't have an ABN and Medicare refuses the claim, you're [...]