Urology Coding Alert

Without ABNs, unpaid Medicare bills may become your problem
 
If you aren't obtaining advance beneficiary notices (ABNs) from patients who  undergo treatments that Medicare may not deem medically necessary, your office could have to pick up the tab on scads of uncovered or partially covered services.

"An ABN is a form that an office treating a Medicare patient has the patient sign if the office is unsure whether Medicare will pay for a certain service," says Kathryn Cianciolo, RHIA, CCS, CCS-P, a Waukesha, Wis., coding consultant for more than 20 years.

Cianciolo says that with the information provided on an ABN, the patient can make a more informed decision on whether he wants to have the procedure performed, given the fact that it's likely he will have to pay for it.

Example: A urologist uses ultrasound guidance for a prostate biopsy. You could report CPT 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the guidance and CPT 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) for the biopsy. However, different Medicare carriers observe different rules on reimbursing for ultrasound guidance codes used during biopsies.

If the patient does not have an approved diagnoses for the ultrasound guidance, but the urologist still feels that the service is medically necessary, the urologist should inform the patient that he may be responsible for the remainder of the bill if Medicare refuses payment. That's where an ABN comes in, Cianciolo says. When Do You Need an ABN?

In general, Cianciolo recommends obtaining ABNs each time a diagnostic procedure may not match up with the proper diagnosis code. If the patient has a diagnosis not listed on your LMRP for the procedure, but the physician still thinks the patient should have the procedure performed, you should have the patient sign an ABN preprocedure.

Also, obtain ABNs when a patient is coming in for a screening procedure but the office is unsure if the procedure will violate Medicare's frequency-period rules.

"For example, Medicare will only cover an annual physical once every 365 days, or it will only cover a blood test or a mammogram every so many days," Cianciolo says. If the doctor sees reason for another screening procedure before Medicare allows you to bill for the procedure again, get an ABN on file.

Smart idea: "You definitely want to make sure you have an ABN if you are unsure about Medicare payment on any service," Cianciolo says.

Medicare does not mandate that you must use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless the doctor's office has a signed ABN.

"If you don't have an ABN and Medicare refuses the claim, you're [...]