General Surgery Coding Alert

Without ABNs, unpaid Medicare bills may become your problem If you aren't obtaining advance beneficiary notices (ABNs) from patients who undergo treatments that Medicare may not deem medically necessary, your general surgery 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, given the fact that it's likely he will have to pay for it.

Example: A general surgeon removes the short saphenous veins in the right leg. You could report 37720 (Ligation and division and complete stripping of long or short saphenous veins) for the procedure. Different Medicare carriers, however, observe different rules on reimbursing for this surgery.

If the patient does not have an approved diagnosis for the vein stripping, but the surgeon still thinks the service is medically necessary, the physician 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 surgeon 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 pretty much out the money," she says. "You're not allowed to bill [...]