Urology Coding Alert

Question: Would you explain when and how we should use an advance beneficiary notice so that our practice doesn't have to absorb the costs of uncovered services?


Virginia Subscriber
Answer: An advance beneficiary notice (ABN) is a written notice that informs the beneficiary that Medicare may not cover a particular service or procedure. By signing the waiver, the patient acknowledges that he will pay for the procedure or service if Medicare does not.

The ABN must clearly identify the service/procedure the surgeon plans to provide, the estimated charge for the service, and state why Medicare may not provide coverage. The ABN affects only those services/procedures you've specifically listed.

You should not give an ABN to a beneficiary if you have no specific, identifiable reason to believe Medicare will not pay (i.e., a "blanket ABN"). In all cases, you should provide the patient with a completed and signed copy of the ABN for his records.

Tip: Make sure Medicare doesn't already have a reimbursement policy on a procedure before you ask a patient to sign an ABN. Obtaining signed ABNs for services Medicare does not pay for is an unnecessary expenditure of time and resources.

If you have some official documentation from Medicare stating that it never reimburses for a service, an ABN is not necessary. You can, however, still use an ABN as a clear indication to the patient that he will be responsible for payment.
 
Remember when the patient has signed an ABN, append modifier GA (Waiver of liability statement on file) to the code you expect Medicare to reject. This way Medicare knows to indicate on the patient's explanation of benefits (EOB) that he "is responsible for payment."

Helpful hint: To obtain a standardized, sample ABN, visit the CMS Web site www.cms.gov and use the "search" function to locate form "CMS-R-131-G."