Medicare Compliance & Reimbursement

The ABN is not a cure-all for your non-paid services.

Confused by the extra paperwork of Advance Beneficiary Notices (ABNs)? Help is at hand.

Myth #1: You should use an ABN any time you think Medicare won't pay for a service.

Truth: You should only use an ABN when something is a Medicare-covered benefit but not covered in this instance, says Jeff Fulkerson with Emory Radiology in Atlanta. So for a screening exam that Medicare never covers, you should use the "GY" modifier (for statutorily non-covered services) instead of the "GA" modifier (meaning you have a signed ABN.)

You should use an ABN when Medicare won't cover a normally covered service because of frequency limitations or a non-covered diagnosis code, says Joan Adler with Adler Advisory Services in Atlanta, GA. You can bill the patient for the service directly as long as you attach the "GA" modifier to the claim. "The ABN is not to be used for services which Medicare never covers." And Medicare doesn't allow "blanket use" of the ABN, she adds.

For example: A physician performs an electrocardiogram (ECG) on a patient with diabetes and no cardiopulmonary symptoms, says Carol Pohlig, senior education and coding specialist with the University of Pennsylvania. The ECG may be medically necessary to obtain information about the possible systemic effects diabetes may have on the heart, but Medicare won't pay for it. The doctor needs to explain to the patient the advantages and disadvantages of the test and let the patient choose, Pohlig says.

Medicare also has limits on how often you can perform some preventive services, such as mammograms and colonoscopies, Adler notes.

Myth #2: You can use an ABN to bill the patient for additional fees beyond what Medicare reimburses for a service.

Truth: If the physician is a participating provider, then you're limited to the Medicare payment allowable for your region. You can't bill the patient extra even with an ABN, Adler insists.

Question: How can you tell if you're using ABNs too often? If you even have to ask this question, it's possible you're overusing them, says Fulkerson.

Rule of thumb: If you're providing ABNs to 1 percent of your patients, you probably don't have a problem. But if you're providing them to 10 percent of patients, then you're above average, Fulkerson says.

If you're receiving a lot of denials for a particular service, you need to figure out what's going on and possibly appeal, says Fulkerson. Don't just start issuing ABNs every time you perform that service.

Bottom line: "ABNs should be the exception rather than the rule," says Adler.