Ophthalmology and Optometry Coding Alert

Hint: If you aren’t aware of coverage guidelines, it’s you who pays — not the patient.

Did you know that an advance beneficiary notice (ABN) issued under the wrong circumstances is almost worse than not having one at all? That’s because if your ABN is found to be issued inappropriately, Medicare can then invalidate all your previous ones — thus making you liable for non-covered services that you performed in the past.

That was the word from Jackie Stack, BSHA, CPC, CPMA, CPB, CPC-I, CEMC, CFPC, CIMC, COPC, CPEDC, during a May 23 Eye Care Leaders webinar on ABNs. Stack covered this and several other ABN facts specific to eye care practices during the event. We’ve rounded up 10 of the tips she shared that can help you when you’re creating your next ABN.

1. Know What the ABN Is

An ABN is a written notice that you give to a Medicare beneficiary to demonstrate that Medicare probably will not pay for specific items or services on that occasion or date of service, Stack said. “This allows the patient to make an informed decision on whether to receive the items or services that he or she may have to pay for out of pocket or through other insurance.” You must maintain the ABN in the patient’s medical record and also provide a copy to the patient for their records as well.

If an electronic ABN is used, the beneficiary must be offered a paper copy. Once the ABN has been executed appropriately, you’ll print it out to give the patient a copy for their records, Stack said.

2. Medicare Presumes Patients Don’t Know Services Are Non-Covered

If a beneficiary tells Medicare that they didn’t know a service would be non-covered and the practice can’t provide evidence to the contrary, the patient is not liable for payment, Stack said. “So the ABN is used as evidence that knowledge to the beneficiary has been given and that they are now liable for that,” she said.

“Maintaining the ABN in the file tells Medicare, ‘We knew it wouldn’t be covered; we gave the patient the option to either have the service and pay out of pocket or to decline the service. They wanted to continue to have it with the understanding that they knew they would have to pay for it,’” she said.

3. It’s Your Practice’s Responsibility to Know Coverage Guidelines

You can’t plead ignorance if you fail to issue an ABN when warranted. “It’s your responsibility as the practice to make sure you know the frequency limits, which diagnoses aren’t covered for tests, and other coverage guidelines, so you’re able to educate your patients with that knowledge as well,” Stack said. “If the doctor requests a test to be performed but we know it won’t be covered, then we have to inform the patient ahead of time with that ABN.”

4. You’re Held Liable If the ABN Isn’t Up to Par

If your ABN doesn’t meet Medicare’s guidelines, you are liable for the cost of the non-covered service — the patient isn’t. “The bar is very high to prove you didn’t know Medicare would deny a service,” Stack said. “You’re held to the standard of knowing Medicare rules and policy and it’s assumed that you’ll keep up with changes. The only way to protect your practice is to properly issue ABNs when limitations of liability apply to your service.”

5. The Patient Must Understand the ABN

If you don’t use Medicare’s specific form, Medicare may rule the form defective and not honor it, Stack said. The beneficiary or their authorized representative must be able to comprehend the notice and you have to use clear language on the form. “No medical jargon or abbreviations that only we understand, because the ABN is for the patient’s knowledge,” Stack said. “If I put something in there that they don’t understand, how do I expect the patient to understand exactly what is the reason it will be denied?”

6. Avoid Blanket ABNs

Some practices believe they should have everybody sign an ABN so everything is covered, but you’re not allowed to do that, Stack said. “If you do expect Medicare to pay, don’t have the patient sign an ABN,” she advised.

“If you issue blanket ABNs and have patients sign them routinely whether or not you expect the insurer to pay, it may cause Medicare to find your ABNs defective, and this will invalidate all issued ABNs and the practice will no longer benefit from the limitation of liability provisions,” Stack said.

7. Skip Blank ABNs

You should never ask a patient to sign a blank ABN and then complete it later. You must fill it out before they sign it, Stack said. The patient must be able to see in writing what the service is and what the reason is for potential denial.

8. ABNs Aren’t Required for Statutorily Non-Covered Services

For services that are never covered by Medicare — such as routine eye care or refractions, or when you’re issuing glasses, a signed ABN is not necessary, but “it is good customer service to inform the patient that the service is not covered,” Stack said. “An ABN can be given voluntarily but is not necessary to be signed by the patient by law.”

For instance, if the patient requests laser vision correction in conjunction with cataract surgery, ask the patient to sign an ABN noting that she understands the laser vision correction won’t be covered.

9. Ordering Services? Get the ABN

An ABN includes both services you perform and those you order, Stack said. “The testing facility for orders depends on you to complete the ABN. For example, let’s say a doctor orders blood work. The test is sent to a laboratory that’s a separate entity. The lab test is denied as not medically necessary. Since the lab is billing for the test and doesn’t have an ABN, the lab is held liable and cannot bill the patient.” To avoid complaints from these entities, it would be good practice to attach a signed ABN to the order, she said.

10. Have Knowledgeable Person Issue ABNs

The person offering the ABN to the patient must respond to beneficiary questions and must also be able to explain why Medicare may deny. It’s not acceptable to say “I don’t know” to the patient’s questions, Stack said. “If you’re educating on an ABN, you should be able to relay information accurately to the patient.”