Gastroenterology Coding Alert

Keep records of unsigned ABN on file even if patient does not sign and return the ABN before the procedure.

If you don’t want to lose out on getting deserved pay for potentially uncovered services, it is better to safeguard your practice’s interests by obtaining an advance beneficiary notice (ABN) from patients when it is appropriate.

Medicare isn’t the only payer requiring ABNs these days, so knowing when and how to obtain patient-payment responsibility agreements is critical to your practice’s bottom line.

Get in line with all of your payers by getting in the habit of issuing ABNs when necessary, so you don’t end up giving your providers’ services away for free.

Arrange an ABN When Medicare Might Not Pay

You should obtain a signed ABN for Medicare patients in the following situations, says Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida:

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

ABN alert: If your patient did not meet medical necessity criteria for getting the necessary coverage, you should get a signed ABN before performing the procedure/ service. You’ll also need to attach modifier GA (Waiver of liability statement issued as required by payer policy, individual case):“Use this modifier when you issue a mandatory ABN for a service as required, and it is on file,” Verno explains. You don’t need to submit the ABN on “GA-modifier” claims, but you should have it available upon request, he adds.

Money matters: Your practice could lose deserved cash if it doesn’t have a signed ABN on file. If Medicare denies your claim and you don’t have a signed ABN, you can’t bill the patient, and your practice is on the hook for the procedure/ service cost.

Get ABN Regardless Of Medicare Statutes

Speaking strictly from a coding perspective, if Medicare explicitly excludes the service by statute, it is not necessary to get an ABN, Verno confirms. Experts recommend getting an ABN in these situations, too. It will show patients that the practice respects them.

When the situation does not explicitly call for an ABN for Medicare compliance, you should move forward with the ABN to present the costs to the patient. Financial care of the patient goes hand-in-hand with their physical and emotional well-being. Worrying about paying an unexpected bill can impact a patient in some pretty negative ways.

Patient perspective: If the patient knows what to expect in terms of financial responsibility, she can better comply with the physician’s directives, because she will know whether she can afford the service. It will also permit her to make a better informed decision about whether or not to receive that service.

ABN Also Aids Patient Relations

In addition to the potential fiscal benefits of ABNs, the documents can actually help you build a more personal rapport with patients.

ABNs build up the trust that the patient has with the provider; they show a respect between the practice and the patient. Most patients appreciate it when the practice takes the time to explain the situation and why an ABN is necessary, so they can decide whether or not to proceed.

Benefit: By giving the patient this kind of respect, it places the provider and the practice in a win-win situation. Patients are people, too.

Strive To Get ABNs Signed By Patient

If at all possible, Medicare wants providers to issue an ABN directly to the patient, Verno says. When this is not possible, Verno says you may issue an ABN through the following means:

• Direct telephone
• E-mail
• Traditional mail
• Secure fax machine.

If you can’t document that the patient received the ABN in person, Verno advises that you note it in the patient’s record. “However, it is difficult to ensure patient comprehension of the document, and that all of the beneficiary’s related questions are answered timely, accurately, and completely to the best of the notifier’s ability,” informs Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

For Medicare to consider an ABN issuance compliant, the beneficiary should acknowledge that you contacted her about the potential costs. Further, you must follow telephone contacts from the patient immediately by a hand-delivered, mailed, e-mailed, or faxed ABN, Verno says.

Then, the beneficiary must send a signed ABN back to your practice.

Cover your bases: In case the patient does not sign and return the ABN before the procedure, Verno recommends you “keep a copy of the unsigned ABN on file. If the beneficiary fails to return a signed copy, document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the ABN,” he explains.

For more information on ABNs and related Medicare policy, please visit the Centers for Medicare & Medicaid Services’ web site at URL: www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.