Coding Consult

An Advance Beneficiary Notice is a form that a medical practice asks a Medicare patient to sign if there's doubt about whether Medicare will pay for a certain service. If you aren't obtaining ABNs, your office will have to pick up the tab on all those uncovered or partially covered services. With the information provided on an ABN, the patient can make an informed decision about whether to have the procedure performed, given the fact that it's likely he'll have to pay for it, and you're allowed to bill the patient.

For example, say a patient has a benign lesion of less than 0.5 centimeters on her kneecap and both you and she think it should come off. If you do the procedure, you'd report it as 11400 (excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) and report 686.1 (pyogenic granuloma) as the diagnosis. But you're unsure if Medicare will accept 686.1 as an appropriate diagnosis code to justify 11400. So you tell the patient that Medicare may not cover the procedure and she might be responsible for the payment. To document her agreement, you have her sign an ABN.

"Medicare accepts the general ABN form—CMS-R-131-G—in all situations," says Kathryn Cianciolo, a Waukesha, WI, coding consultant. She recommends obtaining ABNs each time a diagnostic procedure may not match up with the proper diagnosis code. The general ABN form is available online at www.cms.hhs.gov/medicare/bni/CMSR1312.pdf.

If the patient has a diagnosis not listed on your local medical review policy (LMRP) for the procedure, but you still think she should have it done, get her to sign an ABN beforehand.

Also, get an ABN when a patient is coming in for a screening procedure and you're unsure if it will violate Medicare's frequency-period rules.

"For example, Medicare will cover a specific blood test only every so many days," Cianciolo says. If you see need for another one before Medicare allows you to bill for it, get an ABN on file.

"Medically unnecessary" is not enough

Be thorough when explaining to the patient what services you think Medicare will deny and why, says Thomas Bartrum, a healthcare attorney at Baker, Donelson, Bearman, Caldwell & Berkowitz in Nashville, TN.

"Merely writing that Medicare might deem the procedure medically unnecessary is not enough," he says. In the "Items or Services" box on the form, list all services you think Medicare may deny. In the "Because" box, list all evidence you have to support your stance. That would include details from Medicare's coverage plans, examples of similar cases in which payment was refused, specific details about the patient's claim, and so on. Be as specific as possible.

"The patient will appreciate it, and it will keep you from drawing the ire of CMS' Routine Notice Prohibition police," says Bartrum.

Keep the original ABN for your records and give your patient a copy. Be sure the forms are identical. If there's an inconsistency and the patient complains about it, your office will most likely be the one with the headache, Bartrum says.

Whenever possible, inform patients at the time they schedule an appointment that Medicare may or may not cover the service.

What to change and what to leave alone

When it comes to manipulation of its ABN-G form, Medicare is like a stern but understanding parent—unbending on certain issues yet sensible enough to be flexible when the situation calls for a slight alteration. In fact there are some areas that you can—and in some cases should—customize.

When you file an ABN:

• Alter the header to include your practice's logo (if it has one), name, address, telephone number, and Web site, if available.

• Use at least 12-point Arial or Arial narrow font. Using other fonts or point sizes can render an ABN defective.

• Expand the "Items or Services" and the "Because" boxes if the space provided is not adequate.

• All captions on the ABN should be left alone. Don't make any changes to Medicare's text on the form; you can alter it only for space, not content.

If you make modifications, keep them brief. Under no circumstances will Medicare accept an ABN of more than one page. You can print an ABN on legal-size paper to give yourself more space, but make sure you're submitting only a single sheet.

Don't alter any area of the ABN form not mentioned in this article. Fill out areas completely. (For complete instructions on proper use of ABNs, visit www.cms.hhs.gov/manuals/104_claims/clm104c30.pdf.)

This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.

Coding Consult: When and how to use ABNs.

Medical Economics

Aug. 6, 2004;81:14.