Advance Beneficiary Notices Wisconsin Health Information ...

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Advance Beneficiary Notices Wisconsin Health Information ...

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

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