Wiki Abn forms

[jmcalister]

I am needing some guidance on ABN forms. I have looked up on CMS but I still have questions. I understand by CMS if you looked up the codes with NCD and LCD and looked at frequency or medical necessity you can have a patient fill out ABN with one of these reasons. What about practices that do not look up anything and just have the patient fill out an ABN as a possibly non covered service. IS this right? Do you practice being safe than sorry? Has the OIG ever audited clinics for the ABN's. What reason do you put on the claim and what modifier do you use for a possibly not covered claim? Any guidance would be helpful.

 

[mitchellde]

If you obtain an ABN, you are required to append the modifier, for a mandatory ABN such as you described this will be the GA. However if this dx and procedure combination did not require the ABN, medicare will still deny the service and not patient responsibility. An ABN requires that a modifier be used on the claim, you cannot have one and not the other.
Yes this gets audited all the time. You cannot hedge your bets on this you either know your coverage issues or you don't. If it is never going to be covered like refractions you do not need an ABN nor a modifier, but if you do get an ABN then you use the GY modifier. Again improper use of the modifier can lead to claim denials.
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