EM Coding Alert

Experts: ABN will build patient trust.

Occasionally, a patient will present to the practice for an evaluation and management (E/M) service that Medicare might not pay for completely, if at all.

If you are unsure about whether Medicare will cover a patient’s E/M service, you should obtain an advance beneficiary notice (ABN) to keep compliant. Without an ABN on file, you could be on the hook for any part of the service Medicare doesn’t pay for.

Keep all your bases covered with these tips for handling ABN situations.

Green-Light ABN If Medicare Won’t Pay

According to experts, you should strive to get an ABN “anytime there’s suspicion that Medicare may not cover a procedure that they ordinarily would,” explains Leslie Johnson, CPC, CSFAC,  chief coding officer at PRN Advisors in Palm Coast, Fla.

Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida, says you must issue an ABN when:

• You believe Medicare may not pay for an item or service;
• Medicare usually covers the item or service; and
• Medicare may not consider the item or service medically reasonable and necessary for this patient in this instance.

If you fail to obtain a signed ABN from the patient prior to rendering the service, your practice will not be able to collect any amount due from the patient when Medicare won’t cover for the service.

Extra tip: You might want to start getting proof of advanced patient notice for any service that a private payer might not cover, just to be safe. Some payers will accept the form Medicare created, others want you to use their form — some payers also may not allow you to bill their patients for services not covered. Checking with those payers about any ABN-type notice they’d like you to give to their patients is a good first step.

In short: Payers other than Medicare are now “requesting similar [ABNs] in writing. It’s a good habit for a practice to work into their routine, even if it seems difficult,” Johnson explains.

Medical Necessity, Service Frequency Could Spur ABN

There are many reasons a person might request an E/M service that Medicare might not cover, but here are a few examples:

Example 1: A patient who was put on a medication regimen for high blood pressure on Monday comes back to the practice on Friday. She says she wants to see if this is the “right” medication. She brings in the bottle and asks to see the physician. This is likely a low-level E/M service such as 99211 (Office or outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). Since the physician provided an E/M for the same problem a few days earlier and identifying the pillwouldn’t normally be something medically necessary, Medicare might deny the claim due to lack ofmedical necessity.

Example 2: The practice is offering telemedicine services to a patient. Since telemedicine services are often met with payer denial, you should issue an ABN before providing services 99441 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion) through 99443 (… 21-30 minutes of medical discussion) — as well as 99444 (Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network).

Example 3: A 32-year-old established patient reports to the practice for an ob-gyn physical including a pelvic exam. She had her last physical just over a year ago, and notes indicate she is low risk. Since Medicare covers 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years) every two years for low-risk women, so an ABN might be in order for this E/M service.

ABN Can Help Patient Relations

Remember, if Medicare explicitly excludes a service by statute, it is not technically necessary to obtain an ABN. “However, in these situations, you may issue an ABN voluntarily,” Verno says.

Why? It will help with patient relations. Providing an ABN in any situation where the insurer might not pay “builds up the trust that the patient has with the provider. It shows a respect between the practice and the patient by stating what the cost will be, and giving the patient the choice as to whether they wish to proceed,” Johnson explains.

The patient might not like what they hear about a service being uncovered, but they’ll be a lot less happy if they get an unexpected Medicare bill. “By giving the patient this kind of respect, it places the provider and the practice in a win-win situation.” It also gives them a chance to decide if they want to proceed with the given service or treatment.