All Entries Tagged With: "ABN"
Inpatient HINNs: Protecting the hospital’s right to recover payment for non-covered services
Last week, I participated in an HCPro audioconference on HINNs. “HINN” stands for hospital-issued notice of non-coverage. It’s the inpatient equivalent of an advanced beneficiary notice (ABN). Under Medicare’s limitation on liability (LOL) provisions, hospitals are required to provide prior notice, in a prescribed form, when certain outpatient or inpatient services ordered by a physician do not meet Medicare’s medical necessity guidelines for the patient’s condition.
In such cases, the ABN is the prescribed form of prior notice for outpatient services, while the HINN is the prescribed from of prior notice for inpatient services. Although the prior notice requirements for LOL have been in place for a number of years, hospitals continue to struggle to provide timely, appropriate notification, particularly in the inpatient setting. [more]
CMS announces a coverage determination on the “screening virtual colonoscopy”
On August 7, CMS issued transmittal R105NCD to implement its decision to maintain non-coverage of computed tomography colonography (CTC) for colorectal cancer screening, also known as a “virtual colonoscopy.” In 2008, the medical community had recommended that CMS consider coverage of this exam for screening purposes in specific individuals. After performing its own review, CMS has determined that the current medical evidence is inadequate and that no national coverage determination (NCD) is appropriate at this time.
Currently, Medicare beneficiaries can receive one of the following colorectal cancer screening tests:
- Fecal occult blood test (guaiac-based or immunoassay-based) once every 12 months;
- Flexible sigmoidoscopy once every 4 years depending on risk factors;
- Screening colonoscopy once every 10 years for patients without a known risk;
- Screening colonoscopy once every 2 years for patients at high risk for colorectal cancer;
- Barium enema every 4 years as a substitute for a flexible sigmoidoscopy;
- Barium enema every 2 years as a substitute for a screening colonoscopy for high risk patients.
Since CMS has determined that screening CTCs are non-covered for dates of service on and after May 12, 2009, a signed ABN is not required to be able to bill the patient for the service. However, under the revised ABN instructions, it can be used to inform the patient in advance of their financial responsibility.
More information on covered colorectal cancer screening services can be found in the Medicare Claims Processing Manual, Chapter 18, and the Medicare Benefit Policy Manual, Chapter 1.
Never Events—CMS issues surgical error NCDs and related guidance
In 2002, the National Quality Forum (NQF) published a list of 27 events identified as “serious, largely preventable and of concern to both the public and health care providers.” These events have become more popularly known as “never events”—events that should never occur in a well-run health care facility with appropriate quality controls. The updated list currently contains 28 adverse events, including the following surgical errors:
- Wrong surgical or other invasive procedure performed on a patient;
- Surgical or other invasive procedure performed on the wrong body part; and
- Surgical or other invasive procedure performed on the wrong patient.
Medically Unlikely Edits and medical necessity
Kimberly Hoy previously focused on recently issued FAQ 9697. In FAQ 9697, CMS restated its position that hospitals cannot bill beneficiaries for units of service in excess of MUE limits, even when the hospital has provided an ABN to the beneficiary prior to the provision of the services subject to the MUE. CMS’s rationale is that MUEs are coding edits, not medical necessity edits. [more]
Medically Unlikely Edits and ABNs
This was an especially light week for items from CMS for hospitals. This is, perhaps, because shortly we should see the FY2010 Inpatient Prospective Payment System Proposed Rule.
I did want to discuss a new FAQ on Medically Unlikely Edits (MUEs) that brings up some questions. The new FAQ focuses on Advanced Beneficiary Notices (ABNs), pointing out that a beneficiary can not be billed for units in excess of an MUE even if the provider issues an ABN to the beneficiary. CMS explains that an MUE denial is a coding denial, and that ABN provisions only apply to medical necessity denials. [more]
Prepare for approaching ABN deadline
Medicare has been going through a number of transitions recently. One of these transitions relates to the appropriate form of notice when certain providers, including hospitals and physicians, believe that the outpatient services ordered by the patient’s physician fall under the limitation on liability provisions of the Social Security Act. Under these provisions, the provider must provide advance written notice to the beneficiary (or his or her representative) prior to the performance of the services in order to be able to bill the beneficiary for those services if Medicare denies coverage. [more]
