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ABN: Are they the answer to the “Not Medically Necessary” Dilemma?

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ACE Alert, September 9, 2021 Volume 37
 

Advanced Beneficiary Notices (ABN): Are they the answer to the “Not Medically Necessary” Dilemma?
 
Several of ACE’s clients have contacted the office asking about the new LCD policies that state that anesthesia is rarely if ever necessary with routine pain injections, EGDs and non-screening colonoscopies. 

While ACE can only acknowledge the policies, the only alternative that we know to protect providers is the Advanced Beneficiary Notice process that is in place to help patients decide whether to have the service when it may not be covered by Medicare. Be aware that the ABN process below applies to Medicare Fee-for-Service only and does not apply to the Medicare Advantage program.  Consult the individual Medicare Advantage program for applicable policies.  

The ABN process is not new, but all practices should be aware that it does have some specific requirements of which all practices should be aware.  First, you must issue the ABN on Form CMS-R-131.  The specific guidance for ABNs can be found at:

 https://www.cms.gov/Regulations-and-guidance/Guidance/Manuals/Downloads/clm104c30.pdf

It is important to note that each ABN must be customized to the patient and signed/accepted by the patient prior to the delivery of the service. 
CMS allows ABNs to be issued to transfer financial liability to the patient when an item or service is usually paid for by Medicare under Part B but may not be paid for in this particular case because it is not considered medically reasonable and necessary.  Common reasons for services being deemed not medically reasonable or necessary include:

  • Experimental and investigational or considered “research only”
  • Not indicated for the case’s diagnosis or treatment
  • Not considered safe and effective
  • More services than Medicare allows in a specific period for the corresponding diagnosis

 
Most of the time providers will be issuing the ABN notice at the initiation of care.  When treatment begins and you know or think that Medicare will not cover certain items or services, the patient must sign the notice before the non-covered services begin.  The notice must be 1 page in length and explain why the services are believed to be non-covered. (For example, LCD L33930 does not typically allow for the use of general, MAC and conscious sedation with facet joint intervention).

When filing the claim form to Medicare, append the GA modifier to tell the contractor that you have an ABN on file for the services.  Once the ABN is signed, you can bill the patient and collect for the service(s).  You must make a good faith effort to insert a reasonable estimate for the service(s).  Medicare, in general, expects that the estimate should be within $100 or 25% of the actual cost of the service.  The patient is to be given a signed copy and you must provide the patient with a paper copy of the signed form for their records and retain the notice must also be kept in the patient’s file for 5 years from the date of care delivery.           
 
ACE would encourage anesthesia practices or pain practices delivering anesthesia services to review the ABN process and implement a procedure for anesthesia service(s)you think or know will be denied as not medically necessary.  Failure to obtain the ABN will prohibit the provider from transferring liability for the service to the patient, if Medicare denies the claim as not reasonable or and necessary.

As always, we are here to help with your coding, auditing, and education needs.  Reach out if we can help!

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