Medicare Compliance & Reimbursement

The new advance beneficiary notice (ABN) form has more uses than prior forms, because it incorporates ABNs for physicians and labs, as well as the notice of exclusion from Medicare benefits (NEMB).

To get your brain around how to use this new form, check out these five examples of proper use:

Example 1: Because of personal concerns, a patient asks that a urologist perform a second screening prostate-specific antigen (PSA) determination, although he had one within the last year. By statute, Medicare will only reimburse one screening PSA (G0103) annually.

Medicare most likely won't pay on this second repeat study. You should have the patient sign an ABN to ensure that he understands that he will most likely be financially responsible for this second screening PSA.

Example 2: A patient with laryngeal spasm (478.75) requests a botulinum injection (for instance, 64613) to combat his symptoms. This patient has already received one chemodenervation injection in the past two months. Medicare often limits the frequency of botulinum treatments and will not pay for additional injections during a given time period without evidence of extenuating circumstances.

Because you are unsure whether Medicare will cover the procedure, you ask the patient to sign an ABN. The ABN outlines the service the physician will provide (laryngoscopy with Botox injection) and the reason Medicare may reject payment (excessive frequency). You would report 64613 with modifier GA appended.

Example 3: A patient with chronic lower-back pain requests an epidural injection (62311). This patient has already received six such injections in the past 12 months -- the maximum number his Medicare carrier will reimburse in a one-year period without extenuating circumstances.

Because you are unsure if Medicare will cover the procedure, you ask the patient to sign an ABN. The surgeon provides the injection, and you report the service using 62311 with modifier GA appended. In this case, because the patient has exceeded the frequency guidelines, Medicare denies the claim and sends the patient an EOB.

Example 4: A patient requests a hearing aid (for example, V5244). Medicare does not pay for hearing aids, but the patient's secondary insurer provides coverage. The physician has the patient sign an ABN and appends modifier GY to V5244 to demonstrate that he is aware Medicare does not cover the service.

Example 5: A patient recently diagnosed with intestinal cancer (153.x) seeks a second opinion before undergoing surgery to remove the affected tissue. Your surgeon provides a full workup and discusses possible outcomes with the patient. You ask the patient to sign an ABN to let him know that he may be responsible for payment if the insurer deems the service unnecessary.

For more information on the new ABN form, visit http://www.cms.hhs.gov/BNI/01_overview.asp.