Neurosurgery Coding Alert

Use medical necessity, denial history as a gauge on issuing ABNs.

Depending on your degree of involvement in your practice's administrative process, you may or may not be aware of the role advance beneficiary notices of noncoverage (ABN) play.

An ABN is a provider-issued document given to Medicare patients when the provider suspects that Medicare may deny a particular item or service. While the reasoning may vary, providers will issue the vast majority of ABNs on the basis that Medicare may deny the claim due to lack of medical necessity.

ABN Informs Patient of Financial Burden

When a patient signs an ABN, they are agreeing to pay the provider for a particular service if and when Medicare denies it. The issuance of an ABN does not necessarily mean that Medicare will deny the service; it's more of a precautionary measure taken by the provider in case Medicare denies the service.

As you will discover, there are numerous factors to take into consideration when you or your provider find yourself in a scenario in which issuing an ABN is justified.

Issue an ABN in Certain Circumstances

Only under the appropriate circumstances should a practice consider issuing an ABN to a Medicare patient. According CMS, you must issue an ABN when you believe Medicare will deny a service that they traditionally pay for due to a lack of medical necessity. Additionally, CMS advises your practice should issue an ABN for a particular service if:

• "It is not considered reasonable and necessary under Medicare Program standards;
• "The care is considered custodial;
• "Outpatient therapy services are in excess of therapy cap amounts and do not qualify for a therapy cap exception."

Pay Attention to Triggering Events

Medicare outlines three "triggering" events in which you or your provider should consider issuing an ABN, with the initiation of a new service being the most common scenario. For all new patient encounters, it's the provider's responsibility to assess a given service to determine whether or not it is reasonable and/or necessary under Medicare guidelines.

Another scenario in which you should consider an ABN is in the case of reductions. A reduction of care consists of a decrease (in frequency or duration) of a particular service due to lack of medical necessity. If the patient insists that the particular service still occurs at the same frequency as before, you should issue an ABN to the patient.

Finally, providers need to consider the use of an ABN in the case of a termination of care. If a beneficiary would like to continue receiving care for a terminated service, the patient would likely be required to fill out an ABN due to a suspected denial for the service.

Use this Medical Necessity Definition

Knowing what qualifies as a medically reasonable or necessary service is half the battle when it comes to ABNs. According to CMS, you should refer to this set of criteria when determining which services you should and should not consider medically necessary:

• "Experimental and investigational or considered 'research only';
• "Not indicated for diagnosis and/or treatment in this case;
• "Not considered safe and effective; or
• "More than the number of services Medicare allows in a specific period for the corresponding diagnosis."