Ob-Gyn Coding Alert

Tip: Have an ABN handy for low-risk Medicare patients in for annual Paps

Your practice may be left footing the bill if you fail to obtain an advance beneficiary notice before a patient has a Pap that you know Medicare won't cover.
 
What it is: "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 Waukesha, Wis., coding consultant for more than 28 years.
 
Benefit: With the information provided on an ABN, the patient can make a more informed decision on whether she wants to have the procedure performed, given the fact that it's likely she will have to pay for it. In other words, this educates the patient about what is and what is not covered in advance, says Ann Rodr, CCS, CPC, a veteran ancillary medical coder at UNC Healthcare in Chapel Hill, N.C., with two years of ob-gyn coding experience.
 
Example: A low-risk Medicare patient presents to your office for a Pap smear as well as a pelvic and breast exam. You should report HCPCS codes Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). You should report V72.31 (Routine gynecological exam) for the diagnosis.
 
Here's the rub: Medicare will pay for one Pap test every two years for low-risk patients, and this patient wants to have a yearly checkup. To avoid getting stuck with the Medicare bill, you should inform the patient that she is responsible for this service fee. That's where an ABN comes in, experts say.

When Do You Need an ABN?
 
Medicare accepts the general ABN form (also called the ABN-G) in all situations.
 
In general, you should obtain an ABN 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 ob-gyn still thinks the patient should have the procedure performed, you should get the patient to sign an ABN preprocedure.
 
Example: An ob-gyn performs a diagnostic Pap smear with a diagnosis of history of breast cancer (V10.3). In this case, the carrier will not reimburse this combination of procedure and diagnosis codes. Best bet: Have the patient sign an ABN.
 
Also, obtain an ABN when a patient comes in for a screening procedure but the office is unsure whether the procedure will violate Medicare's frequency rules. Remember: You don't need an ABN if Medicare never covers the service, such as a preventive medicine procedure (99381-99397).
 
Example: Medicare will not cover an annual physical - it will cover a Pap smear (Q0091) pelvic and breast exam (G0101) only once every two years. Also, Medicare mandates that 365 days must pass before it will cover a Medicare patient's next mammogram, Rodr says. So if the ob-gyn sees reason for another screening Pap smear or mammogram before Medicare allows you to report 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 use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless the ob-gyn's office has a signed ABN on file.
 
"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 the patient for it."
 
With a signed ABN on file, however, your office is justified in billing the patient for any part of the bill Medicare won't pay for. The ABN proves to Medicare that the patient understood that she might be responsible for the bill before the procedure was performed, Cianciolo says.
 
It may help to have a blank ABN in front of you while reading this section. A copy of Form No. CMS-R-131-G, the general ABN form, is available online at URL www.cms.hhs.gov/medicare/bni/CMSR131G_June2002.pdf.
 
Except under extremely rare circumstances, the physician should give the patient the ABN before performing the service. Inform patients at the time they schedule appointments that Medicare may or may not cover the service. Then, deliver the ABN ASAP.
 
Note: For a free PDF of a "Medicare Annual Exam Letter Template," provided by Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Guadalupita, N.M., e-mail me at suzannel@eliresearch.com.