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Everybody’s Favorite Form: New Advance Beneficiary Notice of Noncoverage (ABN) Form Begins in 2012

NOTE: We have just added an educational webinar on using the ABN form. This is an expanded webinar with 75 minutes of content and 15 minutes of Q & A with the attendees. Click here to go to our webinar page for more information.

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CMS recently released an updated version of the Advance Beneficiary Notice of Noncoverage (ABN) (form CMS-R-131), which will replace the 2008 version of this form. The 2008 and 2011 ABN notices are identical except that the release date of “3/11” is printed in the lower left hand corner of the new version.  The ABN is used by all providers, practitioners, and suppliers paid under Medicare Part B, as well as hospice providers and religious non-medical healthcare institutions (RNHCIs) paid exclusively under Medicare Part A.

Providers and suppliers may use either the 2008 or 2011 version of the ABN through the end of 2011; beginning Sunday, January 1, 2012, they must begin using the 2011 version. ABNs issued after Sunday, January 1, that are prepared using the 2008 version of the notice will be considered invalid by Medicare contractors.  2008 versions of the ABN that were issued prior to Sunday, January 1 as long-term notification for repetitive services delivered for up to one year will remain effective for the length of time specified on the notice.

Okay, here’s the good stuff that I get questions on all day every day – how do I use the ABN?

 

First, let’s understand WHEN you should use the ABN.

The ABN’s reason for being is to allow the physician practice to collect from the patient for services that the patient wants, but are not covered by Medicare. Practices are not expected to give ABNs to patients to cover services that are never covered (called statutory exclusions), however, many find that it helps the patients understand when they receive a bill for the service. (Note: you may collect in full at time of service if you so choose.) With 2011’s new wellness benefits, some of the primary reasons for using the ABN have gone away. Patients receive a Welcome to Medicare Visit (not an exam) within the first 12 months of the effective date of Medicare Part B coverage. Medicare beneficiaries are eligible for one Annual Wellness Visit (AWV) every 12 months after they have had Medicare Part B for more than 12 months. This is a “visit” and not a physical examination.

Here’s a good example of WHEN you would use the ABN.

A Medicare patient wants an EKG even though she does not have any diagnoses that would point to an EKG being medically necessary. She is not in her first 12 months of Medicare coverage, therefore she does not qualify for an EKG as a part of her Welcome to Medicare Visit (not an exam.) She believes there may be something wrong with her heart, even though she cannot name any symptoms that would warrant a diagnostic EKG. In this case, without a diagnosis to support the EKG, an ABN would be appropriate. You would advise the patient that Medicare may not pay for the EKG, in fact probably won’t pay for the EKG, and you complete the ABN, showing the patient what she will be paying out of pocket for the test. In the case of Medicare not covering the test, you may charge the patient your full rate for an EKG and are not restricted by the Medicare allowable. If the patient agrees to have the test and signs the ABN stating she understands she will be responsible for the cost of the test if Medicare does not pay, you will provide the patient with a copy of the signed form and will will attach the completed form to the patient’s encounter form so the EKG will be billed with the modifier “GA” which indicates an ABN was executed for a service that might be covered by Medicare. In the case where a service is never covered (i.e. statutory exclusions) your Medicare Administrative Carrier (MAC) may require you to append a modifer “GY” when an ABN is signed and on file.

The ABN should be scanned with the encounter form or any other financial paperwork from the visit so it can be retrieved if requested by Medicare during an audit. If you do not archive your paperwork electronically, you should file the ABNs alphabetically by patient name by month. You can also scan the ABN into your EMR.

What are statutory exclusions (services that are never covered) under Part B?

  • Oral drugs and medicines from either a physician or a pharmacy. Exceptions: oral cancer drugs, oral antiemetic cancer drugs and inhalation solutions.
  • Routine eyeglasses, eye examinations, and refractions for prescribing, fitting, or changing eye glasses. Exceptions: post cataract surgery. Refer to benefits under DME prosthetic category.
  • Hearing aids and hearing evaluations for prescribing, fitting, or changing hearing aids.
  • Routine dental services, including dentures.
  • Routine foot care without evidence of a systemic condition.
  • Injections which can be self-administered. Exceptions: EPO, and clotting factors.
  • Naturopath’s services.
  • Nursing care on a full-time basis in the home and private duty nursing. (Refer to benefits under Medicare Part A).
  • Services performed by immediate relatives or members of the household. Services payable under another government program.
  • Services for which neither the patient nor another party on his or her behalf has a legal obligation to pay.
  • Immunizations. Exceptions: Influenza, Pneumovax and Hepatitis B .
  • Wheelchair van ambulance services.
  • Cosmetic surgery.

 

What services doesn’t Medicare cover that you would use an ABN for? 

Services that are covered under the Medicare Program may be limited in coverage due to the following:

  • Certain diagnoses – a service may be covered, but that coverage may be limited to certain diagnoses. For example, vitamin B-12 injections are covered, but only for diagnoses such as pernicious anemia and dementias secondary to vitamin B-12 deficiency.
  • Frequency/Utilization parameters – a service may be covered, but that coverage may be limited if the service is provided more frequently than allowed under a national coverage determination (NCD), a local coverage determination (LCD), or a clinically accepted standard of practice. For example, a screening colonoscopy (G0105) may be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer otherwise the service is limited to once every 10 years and not within 48 months of a screening sigmoidoscopy.
  • Proven clinical efficacy – if a service is considered investigational, experimental, or of questionable usefulness, the service may be denied as not reasonable and necessary. For example, Acupuncture is considered experimental/investigational in the diagnosis or treatment of illness or injury. Claims will deny because procedure/treatment has not been deemed “proven to be effective” by the payer.

 

Probably the hardest question to answer is : WHO should be responsible for getting the ABN signed by the patient?

The Answer is : EVERYONE!

Remember, you can’t have a patient sign a “blanket ABN” to use any time Medicare denies a service as non-covered. That’s fraud. You cannot have the patient sign the ABN after the procedure or service is provided. That’s fraud, too. The only time you may get the ABN signed is before the patient receives the service and after you clearly explain what Medicare might not cover, why they might not cover it, and if they don’t cover it, what the cost will be to the patient.

The WHO is so hard because often the person who has the most knowledge about Medicare (your coder, biller, or manager) sits in the back of the office and might never even see the patient on their way in or out the office. Many practices have given up on the ABN process because figuring out the workflow can be challenging.

Don’t give up! You can implement ABNs in your practice and here’s how:

If you have an EMR, this is a slam dunk because your system should be preloaded with the Medicare service limitations and when you place an order for a service that may not be covered, your EMR should warn you and generate an ABN. Nice!

If you don’t have an EMR, follow these steps:

  1. Review the Medicare coverage guidelines and compile a list of services your group provides or orders.
  2. Print the list with price ranges on the back of the ABN form (turn them over and run them through your printer or copier). You can print your own ABNs with your services and prices, but if you have very many services, you may not have enough room on the ABN. You may also choose to have more than one preprinted ABN –  one with labs, one with services.
  3. Have a full staff meeting to discuss the ABN and your plan to implement a program to use ABNs when appropriate. Discuss the Medicare guidelines and what services your practice provides and educate the staff on the circumstances for which an ABN is appropriate. EVERYONE needs to help each other learn and master ABNs. Make sure everyone understands that the ABN is not in place to take money from Medicare patients – it is an opportunity to educate the Medicare patient
  4. Create a custom chart for your group that combines the services you provide with the associated rules. Post the chart in each exam room, the lab, the check-out station, on the EKG or other medical test equipment and anywhere where an employee should stop and think “Do I need an ABN for this?” Make sure blank ABN forms are available nearby. If you dislike having charts everywhere, create a short word or phrase and print it on bright paper, then post it appropriately. It might be “ABN CHECK” or something like that. Every few months, move the paper to a different place in the exam room, etc. and/or print it on a different color paper. Make sure those most likely to identify the need for an ABN – physicians, mid-level providers, nurses, medical assistants, referral clerks, lab techs – know they can ask for help with the ABN process when they need it.
  5. Some in-house or referral lab systems also furnish ABN information for mismatches on lab services and supporting diagnoses. Make sure and check the lab system before you begin a service!

You can find information and a copy of the 2011 version of the ABN (form CMS-R-131) here  under the “FFS Revised ABN” link.




Who Does What in a Medical Office: Basic Position Descriptions

Front Desk/Check-In

  • Greets patients and visitors to the practice
  • Registers patients in the practice management system which may mean entering information given verbally or on registration forms
  • Collects identification and insurance cards and copies or scans them for the record, may photograph the patient for the record
  • May collect co-pays or other monies
  • Prints encounter form (also called superbill, routing slip, or fee ticket) with updated information, or updates information on the encounter form
  • Has patient sign financial agreement, receipt of privacy policy, benefits assignment, etc.
  • May answer phone calls, take messages and make appointments
  • Directs visitor (drug reps, salespersons, etc.) appropriately

Medical Records

  • Primary responsibility for the integrity and management of the medical record, whether paper or electronic
  • Controls record filing (paper) or indexing (electronic)
  • Fulfills requests by patients, attorneys, insurance companies, and social security for release of records
  • May manage paper faxes and messages by attaching to charts and delivering to provider
  • May prepare paper charts for chart audits by payers or others
  • May be the HIPAA Officer

Medical Assistant, LPN or RN

  • May assist Physician, Nurse Practitioner or Physician Assistant with procedures
  • Depending on state laws, may give injections
  • May perform procedures independently (ear wax removal, staple removal, etc.)
  • Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
  • May perform phlebotomy (draw blood)
  • May collect specimens, perform basic laboratory tests and chart results
  • Provides patient education verbally and by providing written materials
  • May schedule tests or procedures ordered by the provider
  • May schedule surgery and prepare surgery packets for providers (*this may be delegated to a surgery scheduler if this position exists)
  • Calls patients about test or procedure results; returns patients calls with answers after consulting with provider
  • Prepares exam room for procedures (PAP smears, excisions, etc.), marks specimens for lab and pathology
  • Cleans exam room after each patient and stocks exam and procedure rooms with supplies
  • May be responsible for ordering office medications and medical supplies
  • May perform lab controls daily and check and record temperatures on lab refrigerators and freezers

Triage Nurse

  • Takes incoming calls from patients and gives them medical advice according to predetermined nursing protocols
  • Makes decisions about patients needing to be seen urgently, same day or next day
  • May be delegated callbacks from providers or other nurses
  • May see walk-in patients and triage their condition

Lead Nurse, Charge Nurse, or Nurse Supervisor

  • Assigns clinical staff specific responsibilities
  • Manages clinical staff schedules, using agency or temporary staff as needed
  • Performs annual competency exams on staff
  • Ensures all staff are current on licenses, continuing education and CPR
  • Problem-solves patient issues
  • May be responsible for ordering office medications and medical supplies
  • Has responsibility for medication sample closet upkeep
  • May perform annual evaluations fro clinical staff
  • Responsible for equipment maintenance and makes recommendations for medical equipment as needed
  • May be the Patient Safety Officer and the Worker’s Compensation Coordinator

Referral Clerk

  • Reviews orders written by providers and determines where test and procedures may be performed based on patient’s insurance
  • May provide the patient with information about the test or procedure cost and what the patient’s financial responsibility is estimated to be
  • Pre-authorizes, pre-certifies, or pre-notifies the test or procedure if required by the patient’s insurance company
  • Schedules the test or procedure
  • Provides the patient with information about preparation for the test or procedure

Lab Technologist/ Phlebotomist

  • Receives laboratory requisitions from provider and collects specimens according to provider order
  • Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
  • Performs tests or packages specimens to be transported to reference lab
  • Receives results back from the labs and matches them to charts
  • Performs lab controls daily and checks and records temperatures on lab refrigerators and freezers

Check-out Desk

  • Reviews services received by patients, checking to make sure that all services received were checked on the encounter form
  • Enters charges in the computer system for services received
  • Tells patient if any additional monies are owed if co-pay was collected at check-in
  • May sign patient on to a payment plan if needed
  • Takes monies owed, posts monies and produces a receipt for the patient
  • Makes return appointment for the patient if needed, or enters recall into the practice management system

Biller or Collector

  • Corrects claims that are rejected from the claims scrubber, clearinghouse or payer
  • Files secondary and tertiary claims as needed, electronically or via paper
  • Posts receipts from insurance companies and patients and edits any electronic remittance advice; may post from lockbox account on the web
  • May prepare deposits and/or make deposits
  • Generates patient statements
  • May check eligibility on patients with appointments and call patients whose insurance is not active (*may be delegated to a financial counselor if this position exists)
  • Calls patients who have not made payments in response to statements
  • May turn patients over to third-party collectors
  • Takes phone calls from payers or patients about billing issues and resolves issues

Coder

  • Reviews notes from inpatient or outpatient encounters and codes them according to the documentation
  • May post charges for services rendered
  • Audits chart documentation for quality purposes to ensure that provider coding and documentation is synchronous
  • Introduces changes in procedure (HCPCS) and diagnosis (ICD-9) codes and educates staff on the use of new codes
  • Ensures encounter forms and practice management software is updated appropriately with new and deleted codes
  • May be delegated the Compliance Officer

Billing Supervisor

  • Reviews the work of coders, billers and collectors and performs quality audits to benchmark acceptable error rates
  • Prepares or reviews deposits and tracks daily charge, collection, write-off and deposit information, watching for monthly abberations by payer or date
  • Reviews Accounts Receivable (A/R) reports, looking for trending or specific problems to be addressed with staff or payers
  • Brings to the attention of the Office Manager or Administrator any issues with non-standard payment trends, denials or non-covered services.
  • Performs evaluations for billing department staff
  • Takes escalated patient complaints
  • May credential providers with new payers or recredential providers with payers or hospitals

Office Manager, Practice Administrator, or Practice Manager (see the Library tab for job descriptions) see my posts on what an administrator does here, and a day in the life of an administrator here

  • Performs all human resource functions for the practice
  • Has ultimate responsibility for all money flowing in and out of the practice – makes deposits, pays bills, etc.
  • Contact person for all computer system, equipment and phone system issues
  • Responsible for day-to-day operations, advises supervisors on issues and problems
  • Resolves escalated patient complaints
  • Meets with vendors and researches possible practice purchases
  • Negotiates all practice contracts
  • Meets with staff and providers on a regular basis

These descriptions will not perfectly fit most practices, this is just a generalization.  Each practice divides duties based on the number and skills of the staff in their office, and their specialty.  These descriptions should help to define what the basic tasks are in most practices.