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  • 1. Advance Beneficiary Notices Wisconsin Health Information Management Association September 13, 2002 Presented by: Richard Donkle, CPA Rural Wisconsin Health Cooperative
  • 2. Advance Beneficiary Notices (ABNs)
    • Advise Medicare beneficiaries
    • Issued before items or services are furnished
    • Issued when Medicare is likely to deny payment
  • 3. Advance Beneficiary Notices (ABNs)
    • New ABNs
    • CMS published in June 2002
    • CMS-R-131
      • General Use (ABN-G)
      • Laboratory Tests (ABN-L)
  • 4. Advance Beneficiary Notices (ABNs)
    • New ABNs (continued)
    • May not be modified
    • Contain customizable boxes
  • 5. Advance Beneficiary Notices (ABNs)
    • ABNs are issued when Medicare probably or certainly will not pay for an item or service on the basis of one of the following statutory exclusions:
    • Section 1862(a)(1) of the Act
    • Section 1834(a)(17)(B) of the Act
    • Section 1834(j)(1) of the Act
    • Section 1834(a)(15) of the Act
  • 6. Advance Beneficiary Notices (ABNs)
    • ABNs are issued when Medicare probably or certainly will not pay for an item or service on the basis of one of the following statutory exclusions (continued):
    • Section 1862(a)(9) of the Act
    • Section 1879(g)(1) of the Act
    • Section 1879(g)(2) of the Act
  • 7. Advance Beneficiary Notices (ABNs)
    • Section 1862(a)(1), lack of medical necessity, exclusions include:
    • Custodial Care
    • Mammography
    • Pap smear
    • Pelvic exam
    • Glaucoma
    • Prostate cancer
    • Colorectal cancer screening tests
  • 8. Advance Beneficiary Notices (ABNs)
    • Section 1834(a)(17)(B) addresses violation of the prohibition on unsolicited telephone contacts for medical equipment and supplies
  • 9. Advance Beneficiary Notices (ABNs)
    • Section 1834(j)(1) addresses situations where medical equipment and supplies suppler number requirements are not met
  • 10. Advance Beneficiary Notices (ABNs)
    • Section 1834(a)(15) addresses situations where medical equipment and/or supplies are denied in advance
  • 11. Advance Beneficiary Notices (ABNs)
    • Section 1862(a)(9) addresses custodial care
    • Section 1879(g)(1) concerns homebound and intermittent denials for home health care
    • Section 1879(g)(2) addresses items or services provided to a hospice patient who is not terminally ill
  • 12. Advance Beneficiary Notices (ABNs)
    • Use of Condition Codes (Part A):
    • 21 - Item or service is non-covered, but a denial is sought in order to bill other insurance (ABN not required)
    • 20 – Used in a demand bill situation, when an ABN has been issued, but beneficiary still wants Medicare billed
  • 13. Advance Beneficiary Notices (ABNs)
    • Use of Modifiers (Part B):
    • GA - ABN on file
    • GZ - Item or service expected to be denied as not reasonable and necessary (No signed ABN on file)
    • GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit
  • 14. Advance Beneficiary Notices (ABNs)
    • ABNs are not necessary for specifically excluded items or services.
    • Excluded items include:
    • Personal comfort items
    • Most shots (vaccinations)
    • Hearing aids and hearing examinations
  • 15. Advance Beneficiary Notices (ABNs)
    • Excluded items include (continued):
    • Most outpatient prescription drugs
    • Orthopedic shoes and foot supports (orthotics)
    • Health care received outside of the US
    • Services required as a result of war
    • Services paid for by a government entity that is not Medicare
  • 16. Advance Beneficiary Notices (ABNs)
    • Excluded items include (continued):
    • Services for which the patient has no obligation to pay
    • Home health services furnished under a plan of care, if the agency does not submit the claim
    • Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997
  • 17. Advance Beneficiary Notices (ABNs)
    • Excluded items include (continued):
    • Items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of Health and Human Services (except in a case of urgent need)
    • Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless they are furnished under arrangements by the hospital
  • 18. Advance Beneficiary Notices (ABNs)
    • Excluded items include (continued):
    • Items and services furnished to an individual who is a resident of a SNF, or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF
    • Services of an assistant at surgery without prior approval from the peer review organization
  • 19. Advance Beneficiary Notices (ABNs)
    • Excluded items include (continued):
    • Outpatient occupational and physical therapy services furnished incident to a physicians’ services
    • Routine physicals and most tests for screening
    • Routine eye care, eyeglasses and examinations
    • Cosmetic surgery
  • 20. Advance Beneficiary Notices (ABNs)
    • Excluded items include (continued):
    • Dental care and dentures (in most cases)
    • Routine foot care and flat foot care
    • Services by immediate relatives
    • Services under a physicians’ private contract
  • 21. Advance Beneficiary Notices (ABNs)
    • Examples of appropriate uses:
    • Magnetic Resonance Angiography (MRA) to rule out Renal Artery Stenosis – this is not a covered indication for MRA per Coverage Issues Manual (CIM) 50-14
    • Hyperbaric Oxygen (HBO) treatments for a non-healing venous stasis ulcer – this is not a covered indication for HBO per CIM 35-10
  • 22. Advance Beneficiary Notices (ABNs)
    • Examples of appropriate uses (continued):
    • Screening Mammography less than one year since the last
    • An experimental procedure, eg. Vagal Nerve Stimulation (VNS) for Refractory Depression
    • An item or service which is not reasonable & necessary per a Local Medical Review Policy (LMRP), e.g. IV levocarnitine given to a dialysis patient (see UGS LMRP INJ-101)
  • 23. Advance Beneficiary Notices (ABNs)
    • Examples of inappropriate or unnecessary use:
    • ER patient prior to medical screening exam
    • Any patient “under duress”
    • Excluded routine screening tests, e.g. cholesterol testing without symptoms or history of hypercholesterolemia
  • 24. Advance Beneficiary Notices (ABNs)
    • Examples of inappropriate or unnecessary use (continued):
    • Cosmetic surgery
    • Hearing aids
    • Tooth extraction
  • 25. Advance Beneficiary Notices (ABNs)
    • For additional information go to:
    • http://www.cms.gov/medicare/bni/
  • 26. Advance Beneficiary Notices Wisconsin Health Information Management Association September 13, 2002 Presented by: Richard Donkle, CPA Rural Wisconsin Health Cooperative