Understand the What & Whys of ABNs

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You would only have an ABN signed if you KNOW the For Physical Therapy.... do we have to have an ABN on file services were not covered by Medicare. If the the PT is not prior to EACH visit during an episode? For example, a covered expenses then you would need the ABN signed patient comes 3 times a week for 3 weeks. Do we need one and it could cover the entire time the services are ABN for all treatement or one before each visit? performed if notated on the ABN. Should we use an ABN for Medicare preventative carve out It is not required and is considered a voluntary basis only, I services. 99397 doesnt need ABN but should we use it for feel it makes a great communication tool to inform the patient guidance? patient services are not covered If you, as a provider, are not a medicare provider, is an If you don't participate in Medicare you are still required to ABN required and is a patient signature required? inform patient and have ABN signed. The patient would also complete Option 2 of the ABN That is my understand but I would still check with the Are ABN's required when billing to Medicare Advantage individual Advantage plan Plans also? We saw in Medicare Claims Processing Manual Chapter 30 that 'You should only provide ABNs to beneficiaries enrolled in Original (Fee-For-Service) Medicare." Just wanted to see if that was the case? Our physicians do DOT physicals. There is no appropriate code for this service. Can you use unlisted code on ABN?

You would not use an ABN for a DOT, they are used for Medicare services only, DOT's are not Medicare services. However trying to pass off a DOT in place of a Medicare Medicare only pays for a wellness visit so they wouldnt pay wellness exam could be considered fraud. I would be for a DOT physical because patient is not sick and it doesnt hesitant to do this. meet Annual wellness or preventative codes

For services that MAY NOT be covered. For instance, if a patient reaches the $1920.00 therapy cap and we begin to bill with medical necessity KX modifier, there are sometimes when Medicare denies services as not medically necessary even when there is functional progress and RX is current. I'm interested in hearing what other facilities are doing with lab services, do you obtain ABN's and if so at what point in the patients visit to have labs drawn? So in the event that the services may not be covered, we should do a fresh ABN before each visit or one ABN until treatment is complete.

This is more of a statement that an question.

Can a range of cost be listed if it is within the 25% or 100.00? I am unclear ,do we need the ABN for Medicare patients when they come in for DOT physical?

Yes you are correct within 25% or 100.00

I can't answer what other facilities are doing but most important the ABN must be signed before services are performed Either an ABN at each visit or sometimes we have patients with extended or repetitive non covered treatments. In this case you can have ABN signed by the patient listing all items and services that Medicare will not cover, and specify the duration of the period treatment.

If you are billing a DOT physical it has nothing to do with Medicare and would have a regular facility waiver signed not a ABN.

Can the patient change their mind once claims are finalized The original ABN is used with notations of why the patient to bill Medicare in order to be able to appeal? changed their mind, you would not issued a NEW ABN. Make sure the patient signs the annotation ABN and must be a clear indication of their new option selection along with the beneficiary’s signature and date of the change. Again a copy of the changed ABN must be given to the beneficiary. If the benificiary changes their mind after the service are completee how do you change the ABN? You cant do a new one after services complete correct?

It is not very clear on Medicare guideline - Per Medicare "If a related claim has been filed, it should be revised or cancelled if necessary to reflect the beneficiarys new choice" For the power of attorney, is a healthcare power of attorney The patient will have a legal POA designated, it would not or a regular power of attorney? be the physician unless the patient has designated the physician as POA but this would be unusual. For lab services, is it the responsibility of the provider to Yes it is the responsiblity of the provider or Notifier but I complete the ABN when ordering labs that are suspected to would also enter any information of other entities that the not be a covered serive? patient would receive a billing statement from. Medicare covers 2 days/week for PT the ABN would be for the other 2 days? Yes if Medicare would not cover 4 days of PT but the patient wishes to have all four days of PT, you would have an ABN signed by the beneficiary to information them they are responsible for the extra two days because Medicare does not feel it is Medically Necessary.

There are different types of power of attorney, some have all legal rights, some have only medical rights, which would it pertain to?

Medicare has it definitions of "authorized" representative. Refer to the URL at the end of this presentation and reference 50.4.3 for the answer. There are several situations listed. What about the re-coupment , lets say we have ABN onfile This will only depend on how Medicare denies the claim, medicare pays but later on they recoup the payment can we tough question to answer without knowing what the denial bill the patient if we have ABN on file? codes say you can do. When we use a GA modifier....claims deny by medicare as 'invalid mod'...when call they say to use the GY mod on all claims where GA would be appropriate...do you have any suggestions on what to do about this? we are using the GA mod appropriately.

How frustrating for you. I don't understand why they are denying this modifier because it is a standard modifier used. Have you tried to talk with Medicare and why it is denied?

If the patient refuses to sign the ABN, can we still submit with the GA modifier so Medicare processes as patient liability? Can you use a Notice of Exclusion from Medicare Benefits (NEMB) form CMS-20007 in place of an ABN? Can the NEMB be used for Medicare Advantage or commerical carriers? If the patient refuses to sign the ABN, can we still submit with the GA modifier so Medicare processes as patient liability? I know that the ABN is for Medicare pts only so how are do other insurances handle this?

No I would use the ABN GZ

I would say no because the bottom of this form indicates it is a general summary of exclusions from Medicare benefits and is not a legal form.

I would document this information in box H of the ABN. If you want to have a witness you can but is not required. Your facility should have a waiver of liability for all other insurances that informs the patient of their liability that are non-medicare patients

Can you clarify the use of the GU modifier (waiver of liability) routine notice, since ABNs are not used on a routine service basis? Where do you document patient refusal to sign? Is a voluntary ABN a form that needs filled out?

This modifier identifies to Medicare that you did inform the patient the services are not covered and you are volintarily giving them the information. In box H and can have this signed by a witness but is not mandatory A voluntary ABN is the regular ABN and is called voluntary because we choose to information patient that services are not covered. These are for services that are not routinely covered by Medicare

Should we use the GA modifier on all claims that we obtain an ABN on? Say we thought the max limits had been This will depend on how and what services/procedures the reached and then found out afterwards that the patient had ABN was signed. If the ABN is for the year, then yes you one more injection remaing for the yr. could use the GA modifier. Just be very careful that you have an ABN to support using the GA modifier Is it acceptable to have a COMBO form, i.e., one designed I am confused on this question and what they are asking. with all of the required components of the Medicare ABN but also includes Medicaid and Managed Care as carriers as well as the GA Modifier? Can abn be used for medicare advantage plans? It is usually used for FFS Medicare plans but I would double check with the Advantage plan If we do not need to have patients sign voluntary ABN's, This modifier identifies to Medicare that you did inform the then why do we need to have Modifier GX on the patient the services are not covered and you are volintarily procedure? giving them the information.

Can you enhance the Form CMS-R-131 and indicate that it The ABN is for Medicare patients only and not private or is for Medicare / Medicaid / Managed Care / GA other insurances. Medicaid can differ from state to state Modifiers? but many have their own forms for noncovered services. You can customize a ABN but must be reviewed but an important note that any Modifications of CMS ABN form are not permitted without approved customization by Medicare