Oncology & Hematology Coding Alert

Updated form replaces existing ones March 1.

Almost a year ago -- March 3, 2008 -- CMS implemented its revised Advance Beneficiary Notice of Noncoverage (ABN) (CMS-R-131). Providers and suppliers could choose whether to use the new form or continue filing the familiar ABN-G, ABN-L, or NEMB forms, but those days are numbered. Although your office should have made the change during the six-month transition period, the ABN-G and ABN-L forms will no longer be valid beginning March 1, 2009.

ABNs and waivers can be two of your best reimbursement tools when your oncologist schedules a patient's lab work. In some cases, you-ll want the ABN because of the potential test results; in others, you-ll use an ABN because of the test's timing.

Results dependent: "For many in-house lab tests, Medicare pays if the lab results are on the list of payable diagnoses per the LCD, NCD, or unpublished guidelines for medical necessity within your carrier/contractor, although the ordering sign or symptom may not be on that list," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. "When the ordering diagnosis is not payable and the final diagnosis is not one of the payable diagnoses, the patient will be financially responsible."

"That's why you always have the patient sign an ABN for labwork if the ordering diagnoses are not definitively and clearly payable," Cobuzzi adds.

When you submit the claim, append modifier GA (Waiver of liability statement on file) to alert the carrier that the patient signed a waiver for the test. Do not use the GA modifier if you cannot provide Medicare with a copy of the signed ABN for that date of service and the particular service.

Some tests have built-in timing restrictions that mean Medicare won't pay for multiple tests or tests that occur too frequently. Those circumstances should also tip you toward filing an ABN.

Example: Medicare covers an annual digital rectal examination (DRE) and prostate-specific antigen (PSA) test for males over age 50, but 11 months must pass since the month when Medicare last paid for the services. If Medicare paid for a screening PSA test on Feb. 15, 2009, it will not pay for another screening PSA test for the same patient until Feb. 1, 2010.

If your oncologist orders (or the patient requests) a screening PSA before that time, you-ll need an ABN stating that the patient will pay the charges.

Once you file the claim, submit G0103 (Prostate cancer screening; prostate specific antigen test [PSA]) for the screening (for a Medicare patient). CPT includes three codes to select from: 84152 (Prostate specific antigen [PSA]; complexed [direct measurement]), 84153 (- total) and 84154 (- free) for a diagnostic PSA procedure.

The new ABN replaces the previous ABN-G (for physicians and therapists) and the ABN-L (for laboratories). It also incorporates the Notice of Exclusions from Medicare Benefits (NEMB), which is good news for staff who struggled to differentiate between ABNs and the NEMB. CMS expects the new, combination form to "eliminate any widespread need for the NEMB in voluntary notification situations," according to the new ABN Form Instructions document.

The previous distinction: In the past, ABNs were only for procedures that Medicare might not cover due to medical necessity (limited by LCD, NCD, frequency, etc.); the ABNs didn't apply to procedures or items that were statutorily excluded from Medicare benefits (such as cushions or other comfort items for oncology patients). That was when you used the NEMB as a back-up: for services beyond the stated limits (that didn't fall under an exception) because Medicare never covered them.

"Practices are not required to use an NEMB, but it's good business to notify and inform patients that they are receiving a service that's not covered by Medicare and the cost will fall to them," Cobuzzi says.

Easy fix: Now CMS accepts the new ABN for either purpose, noting that "the revised version of the ABN may also be used to provide voluntary notification of financial liability."

Keep these aspects of the new form in mind:

- a new official title, the "Advance Beneficiary Notice of Noncoverage (ABN)," to explain its purpose more clearly

- a replacement for the ABN-G and ABN-L

- a tool for voluntary notifications in place of the NEMB

- a mandatory field for cost estimates of the items/services in question

- a new beneficiary option, allowing patients to choose to receive an item or service and pay for it out-of-pocket rather than submit a claim to Medicare.

Remember: ABNs help patients decide whether they want to proceed with a service even though they might have to pay for it, says Kara Hawes, CPC-A, with Advanced Professional Billing in Tulsa, Okla. A signed ABN ensures that your clinic will receive payment directly from the patient if Medicare refuses to pay. Without a valid ABN, you cannot hold a Medicare patient responsible for the denied charges.

You can find the new ABN form and filing instructions at www.cms.hhs.gov/BNI. Click on the link for "FFS ABN-G and ABN-L," then download the forms and instructions for "Revised ABN CMS-R-131."