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Medicare ABN's and Modifiers

George Posted Thu 20th of December, 2018 11:39:30 AM
Is it required to notify Medicare if a pt signed an ABN for a service? For example: A patient comes in for a screening mammogram and has not waited the required amount of time (365 days) before having the next mammogram, or they are not old enough to have a screening mammogram under Medicare guidelines (age 40), and we provide the ABN which the patient signs and chooses option 1 on the ABN. Are we required to notify Medicare that the patient signed the ABN in order to be able to bill the patient for the services if they are denied or do we just have to have an ABN on file in order to be able to bill the patient for the services? If it is required that we notify Medicare that the ABN was signed which modifier would be appropriate?
SuperCoder Answered Fri 21st of December, 2018 05:59:12 AM
George Posted Tue 08th of January, 2019 12:08:29 PM
I do not have access to all of the articles above. Please provide the details. Thank you.
SuperCoder Answered Wed 09th of January, 2019 01:17:03 AM

ABN protocols can have residual effects on patient relations.

As difficult as it might be to obtain advance beneficiary notices (ABNs) from patients when appropriate, experts recommend that you jump on the ABN bandwagon, because it’s only getting more crowded.

Medicare isn’t the only payer requiring ABNs these days, so knowing when and how to obtain patient-payment responsibility agreements is critical to your practice’s bottom line.

Get in line with all of your payers by getting in the habit of issuing ABNs when necessary, so you don’t end up giving your providers’ services away for free.

Obtain An ABN When Medicare Might Not Pay

You should obtain a signed ABN for Medicare patients in the following situations, says Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida:

  • You believe Medicare may not pay for an item or service;
  • Medicare usually covers the item or service, but might not for some reason; or
  • Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

Example: A Medicare patient insists on a colonoscopy, even though he does not meet the medical necessity criteria for the screening. The gastroenterologist performs a flexible diagnostic colonoscopy. On the claim, you would report 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).

ABN alert: Since the patient did not meet medical necessity criteria for the colonoscopy, you should get a signed ABN before performing the procedure. You’ll also need to attach modifier GA (Waiver of liability statement issued as required by payer policy, individual case): “Use this modifier when you issue a mandatory ABN for a service as required, and it is on file,” Verno explains. You don’t need to submit the ABN on GA claims, but you should have it available upon request, he adds. (See the sidebar “Keep This Table Close To Aid ABN-Related Modifier Choice” on page XX for more on ABN modifiers.)

Money matters: In the above scenario, your practice could lose deserved cash if it doesn’t have a signed ABN on file. The 45378 code pays about $400 (11.06 nonfacility relative value units [RVUs] multiplied by the Medicare conversion rate of 35.9335). If Medicare denies the claim, which you know they will in this case, and you don’t have a signed ABN, you can’t bill the patient and your practice is on the hook for the procedure cost.

Get ABN Regardless Of Medicare Statutes

Speaking strictly from a coding perspective, if Medicare explicitly excludes the service by statute it is not necessary to get an ABN, Verno confirms. Experts recommend getting an ABN in these situations, too. It will show patients that the practice respects them.

When the situation does not explicitly call for an ABN for Medicare compliance, Johnson says you should move forward with the ABN to present the costs to the patient. “Financial care of the patient goes hand-in-hand with their physical and emotional well-being,” she explains. “Worrying about paying an unexpected bill can impact a patient in some pretty negative ways.”

Patient perspective: If the patient knows what to expect in terms of financial responsibility, she can better comply with the physician’s directives because she will know whether she can afford the service, says Johnson.

ABN Also Aids Patient Relations

In addition to the potential fiscal benefits of ABNs, the documents can actually help you build a more personal rapport with patients, Johnson says.

“[ABNs] build up the trust that the patient has with the provider; it shows a respect between the practice and the patient,” she says. In her experience, Johnson says that most patients appreciate it when the practice takes the time to explain the situation, and why an ABN is necessary, so they can decide whether or not to proceed.

Benefit: “By giving the patient this kind of respect, it places the provider and the practice in a win-win situation. Patients are people, too,” Johnson adds.

Strive To Get ABNs Signed By Patient

If at all possible, Medicare wants providers to issue an ABN directly to the patient, Verno says. When this is not possible, Verno says you may issue an ABN through the following means:

  • Direct telephone
  • E-mail
  • Traditional mail
  • Secure fax machine.

If you can’t document that the patient received the ABN in person, Verno advises that you note it in the patient’s record.

For Medicare to consider an ABN issuance compliant, the beneficiary should acknowledge that you contacted her about the potential costs. Further, you must follow telephone contacts from the patient immediately by either a hand-delivered, mailed, e-mailed, or faxed ABN, Verno says.

Then, the beneficiary must send a signed ABN back to your practice.

Cover your bases: In case the patient does not sign and return the ABN before the procedure, Verno recommends you “keep a copy of the unsigned ABN on file. If the beneficiary fails to return a signed copy, document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the ABN,” he explains.

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