EM Coding Alert

Question: A 32-year-old established patient visited our practice for an ob-gyn physical that included a pelvic exam. She had her last physical just over a year ago, and the notes indicate that she is low risk. Someone in the practice mentioned we may need to file an ABN for this claim. Can you explain what this means?

California Subscriber

Answer: 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 ensure compliance.

In your case, if the patient was a Medicare patient and 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, an ABN might be in order for this E/M service.

According to experts, you should get an ABN anytime there's suspicion that Medicare may not cover a procedure they ordinarily would. Make sure you 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.

Remember: 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 a private payer might not cover, just to be safe. Some payers will accept the form Medicare created, others may 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.