Practice Management Alert

Medicare does not want to receive ABNs in some situations

Medical office billers are aware that they need to get a signed Advance Beneficiary Notice (ABN) from Medicare patients before providing services in some situations, but Medicare payers also have rules against sending ABNs in some instances.

When a Medicare patient reports to the office for a chest x-ray but does not have a Medicare-covered diagnosis, you need to make sure the patient signs an ABN before the physician performs the procedure. That way, your office can bill the patient for the service if Medicare denies the claim.

But there are certain scenarios that Medicare considers ABN-worthy and some it does not, said Stacie L. Buck, RHIA, CCS-P, LHRM, vice president/managing partner of Southeast Radiology Management in Stuart, Fla., during the recent Coding Institute teleconference -ABNs From A to Z: How to Get Paid for All the Services You Provide.-

ABN situations: There are three reasons you-ll have to get an ABN. Specifically, carriers may cover services:

- Only for specific diagnoses/conditions. For example, EKGs, CAT scans and chest x-rays require a specific diagnosis code(s) for coverage. If a patient does not have a covered diagnosis, you-ll need an ABN.

- Only when documentation supports medical need.

- Only when the frequency is within acceptable standards. For example, average-risk beneficiaries over age 50 are only allowed a covered screening colonoscopy once every 10 years. So if a patient had a screening in 1998 and wants another one next week, you-ll need an ABN.

- Only when frequency is within the time-frame standards determined by Medicare. You should check your local coverage determinations (LCDs) for the specific time frames for certain procedures. For example, pelvic exams, mammograms, and colonoscopies are all subject to LCD time frames.

Non-ABN situations: While most of your ABNs will be necessary, it is possible to file a pointless ABN if you-re not careful. In certain instances, Medicare does not want you to get an ABN from a patient, Buck said. These include instances in which the item or service is not a Medicare benefit, Buck said.

Also, for services Medicare is expected to pay for  (e.g., office visits that are not for routine physicals, covered procedures, and diagnostic testing), it is not necessary to obtain an ABN, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

Why? These anti-ABN rules are in place to prevent a deluge of unnecessary documentation from medical offices that fire off ABNs too often, Buck said. -Essentially, what Medicare is saying is that you should not give ABNs out arbitrarily. When you give a patient an ABN, you have to have a good reason as to why Medicare may not pay,- Buck said.