Pathology/Lab Coding Alert

In other words: CMS has updated the ABN form and guidelines to solidify the fact that providers cannot bill dual eligible beneficiaries when the ABN is furnished.

“Dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication,” the new ABN guidelines state. “Strike through Option Box 1 as provided below:”

• OPTION 1. I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.

In black and white: “Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual eligible beneficiaries,” CMS says in the ABN instructions. “If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination.”

Get Back to ABN Basics

Updating your ABN form provides a perfect opportunity to brush up on how and when your lab needs to use these forms.

Key: “You should have a signed ABN on file when you have good reason to believe the diagnostic service your lab or pathologist is providing won’t be covered, and that often relies on medical necessity and coverage issues,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Laboratory conundrum: Because labs typically don’t assign the ordering diagnosis or determine testing frequency, you’ll often need to rely on your physician clients to determine and document that a service is covered or issue the ABN on your behalf.

With that caveat, here are some ABN essentials you should keep in mind:

Never use “blanket” ABNs: Your lab should not regularly require patients to sign ABNs “just in case” a payer denies a service. Instead, you must be sure that there is a reasonable basis for noncoverage associated with the issuance of each ABN, CMS says in its publication, “Advance Beneficiary Notice of Noncoverage.”

Covered services: For services that are normally a covered benefit but may not be covered due to lack of medical necessity or breach of frequency requirements, you must have a signed ABN if you want to collect payment from the beneficiary. You must issue the ABN when:

• You believe Medicare may not pay for an item or service;
• Medicare usually covers the item or service; or
• Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

Generally not covered: You aren’t required to have a signed ABN on hand for services that are never covered by Medicare. However, some experts recommend getting an ABN even when you know Medicare statutorily doesn’t cover a particular service, because it engenders patient good will. Getting the signed ABN means you’re notifying the patient upfront that they will be responsible for a charge and how much they’ll expect to pay, ensuring that everyone is on the same page financially.

“ABNs used for non-covered services provide the documented proof that the patient made an informed choice to proceed with the service,” says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Be sure you use language in the ABN that the patient can easily understand — use verbal descriptions, not CPT^® and ICD-10-CM codes, to describe the procedure and the patient’s medical condition. Include an estimate of the cost of the services. The patient must select an option and sign the ABN. In the case where the patient refuses to choose an option, you must annotate the form to that effect. Medicare payers may deem invalid forms that are incorrectly or incompletely filled out.

Where to keep it: You are required to provide the patient with a copy of the signed ABN, and your lab should keep the original ABN on file.

Resource: To access the new ABN form and the latest instructions, visit https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.