Training Programs
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Regulatory MonitoringArchive for ABN
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
Last month, 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.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
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.
Help ensure your facility properly obtains ABNs from patients for Medicare noncovered services with this auditing checklist.
Click here to download the sample ABN Audit Preparation tool.
Editor’s note: This sample tool is excerpted from the Medical Necessity Training Toolkit, published by HCPro, Inc.
By Kimberly Hoy, regulatory specialist for HCPro
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.
However, CMS also recently updated FAQ 8736 related to reporting medically necessary units in excess of an MUE. They discussed the use of several modifiers to report medically necessary excess units on separately lines. This implies that there are excess units that are medically necessary and other instances where the excess units are not medically necessary. The excess units provided, but judged as not medically necessary, would presumably not be reportable with the indicated modifiers and would be subject to the MUEs. The reason they fail the edit then, seems to be a lack of medical necessity rather than a coding error. This seems to indicate that perhaps there are some services in excess of MUEs that are legitimately provided, but not medically necessary; however, CMS has categorized them as “coding denials.”
I do want to caution providers that, normally, denials that are outside of the ABN provisions result in the service then being billable to the patient without an ABN, as they are only protected from liability for services within the ABN provisions. However, CMS has previously stated in Program Integrity Manual Transmittal 178 that excess units may not be billed to the patients. Further, CMS stated in that same transmittal, as well as in FAQ 8737, that there is no appeal process for these MUEs. This is the only time I am aware of that the hospital can not be paid by anyone, under any circumstances, for services they legitimately provided.
CMS has provided two contacts for giving feedback and making inquiries about the MUEs. If a provider wants to request a change to the value of an MUE, they would do so through National Correct Coding Initiative, Correct Coding Solutions, LLC, P.O. Box 907, Carmel, IN, 46082-0907. The fax number is 317/571-1745. For general inquiries, they have provided the following contact at CMS in FAQ 8741: valeria.allen@cms.hhs.gov.
CMS issues updated lab NCD manual
CMS has posted the April 2009 version of the NCD manual for clinical diagnostic laboratory services on its Web site.
FAQ: May an Advanced Beneficiary Notice (ABN) be utilized to bill the beneficiary for services denied due to an MUE?
A provider/supplier cannot bill the beneficiary for services denied due to an MUE. An MUE denial is an initial determination based on a coding denial, not a medical necessity denial. By statute an ABN may be applied only if the initial determination on a claim results in a denial due to medical necessity. If a provider appeals an MUE denial and some UOS are denied as not medically necessary, the provider should NOT apply an ABN to bill the beneficiary. An appeal is not an initial determination, and by statute the ABN provision only applies to the initial determination.
Q. Do we include a copy of the Advance Beneficiary Notice (ABN) with the claim form?
A. No, do not submit a copy of the ABN unless requested to do so by the carrier.
Source: Centers for Medicare & Medicaid Services
By Jackie Birmingham, RN, BSN, MS, CMAC.
A Medicare beneficiary (or authorized representative) who has been given an Advance Beneficiary Notice of Noncoverage (ABN) may elect to receive the item or service anyway. In this case, the beneficiary should indicate that he or she is willing to be personally and fully responsible for payment by marking options 1 or 2 in box G on the ABN form. This new version of the ABN is used before services are rendered (as the name implies) and it may be given by outpatient department staff.
Here are some more tips regarding filling out the ABN:
- Option 1 indicates the beneficiary or representative will pay for the service out of pocket, but the hospital will also bill Medicare to see whether Medicare will pay for the item or service. If Medicare does not pay, the patient has the opportunity to appeal, but there is no guarantee Medicare will pay for the item or service.
- Option 2 indicates the individual accepts full financial responsibility for the item or service. Medicare will not be billed, and the beneficiary cannot appeal. This option requires that the patient be informed of the cost of the service prior to receiving the service.
- When a beneficiary decides to decline an item or service, he or she should indicate this by marking option 3 in box G on the ABN form. Counseling the patient on this decision and documenting the discussion is important. The service has been ordered based on the patient’s physician’s advice, and if the patient declines the item or service, it is important to be sure that he or she is fully informed of the consequences of the decision.
- The beneficiary cannot refuse to sign the ABN and still demand the item or service.
- If a beneficiary refuses to sign a properly executed ABN, the notifier should consider not furnishing the item or service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.
- Additionally, the notifier may annotate the ABN, and have the annotation witnessed, indicating the circumstances and persons involved.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
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.
Limitation on liability is likely to arise in the outpatient setting when the services ordered fail to meet Medicare coverage criteria for one of the following reasons:
- They fail to meet Medicare’s medical necessity guidelines;
- They are screening services that are provided more frequently than Medicare provides a benefit for; or
- They are custodial services.
In order to successfully shift financial liability to the patient, the provider must provide a prescribed form of notice prior to the performance of the services. Medicare is currently phasing out the prior prescribed forms (ABN-G and ABN-L), which continue to be effective through February 28, 2009. On and after March 1, 2009, however, providers must use the revised ABN form (CMS-R-131) in order for the advance notice to be effective when limitation on liability applies to outpatient services.
The revised form initially became effective for services provided on and after March 3, 2008, which gave providers a year to transition to the revised form. There are a number of technical requirements set out in the Medicare Claims Processing Manual, Chapter 30, that must be met if the ABN is to be effective. Most of the requirements that apply to the revised form are very similar to those that applied to the prior forms.
In September, 2008, Medicare issued Medicare Claims Processing Manual Transmittal 1587, which contained specific, updated instructions on completion and use of the revised ABN. The most significant change is the requirement that “Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed . . .” on the ABN. Nevertheless, Medicare permits a great deal of flexibility in meeting this standard. For example, so long as the estimate is within $100 or 25% of the actual costs, whichever is greater, the notifier will be considered compliant.
With just a month left during the ABN transition period, it is essential that providers assure that they are prepared to be fully compliant with the new requirements, including a good faith cost estimate, as set out in the updated sections in Chapter 30 of the Medicare Claims Processing Manual.
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