By: Zach Simpson
Due to the increasing number of forms being required these days it is all too common for practices to get lost in the vast terminology, rules, and coding requirements that have to be followed as well. An area that practices have one of the most difficult times with is operationalizing the issuance of an ABN properly. I am frequently asked to consult for practices that ask who does which part, when, and with whom in regards to ABNs? In other instances, many practices I have worked with simply make the mistake that they can solve the complexities of trying to understand the nuances of how to properly utilize ABNs by deciding to issue ABNs to every Medicare patient for every service which is not a viable option either. The solution that many offices try that I just described is called issuing blanket ABNs, which in turn may cause Medicare to invalidate all issued ABNs from the practice, including those that may been appropriate which is why it is very important that blanket ABNs are never issued.
One thing in common with practices that issue ABNs in a proper manner is that they all have a process in place for identifying potential denied services prior to delivering them. To many practices this may sound easy, but to ensure that your practice is as effective as possible it will take some claims data analysis to ensure that your practice is capturing all potential opportunities for ABN issuance. The aim of this article will be to provide practices with 5 steps that will make ABN issuance easier.
- Before issuing ABNs it is best to determine which services actually warrant an ABN
To best complete this step it is advised that your practice begin by conducting a review and analysis of your practice’s services and corresponding Medicare denials. The desired outcome is to identify patterns in Medicare coverage determinations and policies where commonly performed services are likely to be denied. Once an analysis has been performed each practice should compile a list of common procedures where an ABN may be appropriate. After compiling the list of common procedures practices should then compare the list toe the provider’s schedule (usually at least a day ahead of time), much like the way your practice determines pre-certifications and/or prior authorizations. In the instance that a patient is added to the schedule the same day as their appointment your staff should check the list of procedures that may be non-covered due to coverage limitation, and if the procedure is on the list proceed to step 2.
Additional Takeaway – Required vs. Voluntary ABN
The service or item is a benefit of Medicare (normally payable) but due to restricted coverage will not be paid, for example:
- Therapy services that have exceeded the cap amount
- Exceeded frequency limits
- Not reasonable or Necessary (ex: diagnosis restriction)
The service or item is not a benefit of Medicare (never payable). The use of the ABN in this circumstance is a courtesy to the patient, so that the patient can make an informed decision prior to the service being rendered. It also allows your office to provide documentation in case the cost of the service to the patient is questioned at a later date.
- Prior to issuing the ABN portions A-F & H should be completed
Step 2 is frequently completed by the billing, coding, or administrative staff. It is recommended that clinical staff is consulted to ensure that the item, procedure, service, test, care, or equipment is accurately described on the ABN in patient-friendly terms. Be sure that following the consultation with the clinician that the services rendered in blank D are described, and in addition some practices prefer to include the CPT/HCPCS Level II codes
- Review the ABN with the patient
It is best to ensure that the individual in your practice that is tasked with this step has a thorough understanding of both the clinical aspect and why the service is being considered, and the reason Medicare is not likely to cover. In addition, the employee needs to be prepared to answer any questions a patient may have that will help them to determine their correct course of action.
- After reviewing the ABN with patient have the patient complete sections G, I & J of the ABN
In order to ensure that Medicare does not invalidate the ABN it is vital to ensure that the patient is given time to review their options and make an informed decision. Following the patient’s decision, they must complete sections G, I, and J of the ABN to indicate how they would like to proceed meaning whether they want to receive the service and, if so, whether they want the service billed to Medicare.
- Proceed Accordingly
The provider will be advised by the patient how they prefer to proceed. Although it may take some effort to properly implement ABN issuance, it’s worth the effort in the dollars a practice may be able to collect that would have otherwise been written off as a loss or recouped.
For any additional clarifications or questions regarding ABNs be sure to contact a healthcare attorney. Remember it is more cost effective to clarify uncertainties with an expert than it is to have to reimburse Medicare for claims submitted with improper ABNs.