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. Add ABNs to Your Arsenal -- But Know There's No Guarantee 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many in-house lab tests, Medicare pays if the lab results are on the list of payable diagnoses per the LCD, NCD, or unpublished guidelines for medical necessity within your carrier/contractor, although the ordering sign or symptom may not be on that list," says Barbara J. Cobuzzi, MBA,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. Take Care With the Timing 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 [...]