Radiology Coding Alert

Not sure how exact the estimated cost must be? Try this tactic.

Advance Beneficiary Notices (ABNs) help patients decide whether they want to proceed with a service even though they may have to pay for it. A signed ABN ensures that the physician 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.

As your practice prepares to switch over to the updated ABN (see "3 Updates Keep You Ahead of the Pack on MPFS, MRI, and ABN Changes" on page 59), keep these ABN essential truths in mind so you don't run afoul of CMS's coding rules.

Avoid "routine" ABNs: Some practices give patients ABNs for the majority of their services to cover them "just in case" Medicare denies the service, but that constitutes an inappropriate use of the form. "Providers and suppliers 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 (ABN)," available at www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf.

Know when forms are considered "voluntary": In situations where you perform a service that Medicare statutorily excludes or never covers, you aren't required to  issue an ABN to the patient, but you can do so.

Deliver the ABN properly: CMS defines an "effective" ABN delivery when you give the ABN to the beneficiary or his representative, and you meet the following criteria:

• The ABN is delivered (preferably in person) and comprehended by a suitable recipient. If you don't deliver it in person and use an alternate method (such as fax, email, or mail), you must document the contact in the patient's records, and the patient must subsequently send a copy of the signed notice back to you.
• The approved, standardized ABN is completed.
• You offer the ABN far enough in advance of potentially noncovered services to give the patient time to consider all available options.
• You explain the ABN in its entirety and answer all related questions.
• The patient (or his representative) signs and dates the ABN and checks one of the option boxes.

Know how to complete the "estimated cost" field: One of the most puzzling aspects of an ABN is how to determine the estimated cost of a service. CMS does offer some guidance.

You may not be able to predict the exact amount that the service will cost, but you must make a "good faith effort to insert a reasonable estimate," which should be within $100 or 25 percent of the actual costs, whichever is greater. For example, CMS notes, if you expect the estimated cost for a service to be about $250, you can enter "Between $150- $300." You also can choose a format similar to "No more than $500" on the form. In addition, CMS notes, multiple services or items that are routinely grouped "can be bundled into a single cost estimate."