Advance Beneficiary Notice of Noncoverage - hmebillers.com fileimply any form of endorsement. CPT...

9/30/2013

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Advance Beneficiary Notice of Noncoverage

P t d bPresented by

Noridian Provider Outreach and Education

Jurisdiction D DME MAC

October 2013

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DisclaimerThis information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety, but may not be modified, soldLLC. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at www.noridianmedicare.com/dme and the CMS website at www.cms.gov.

The identification of an organization or product in this information does not g pimply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2013 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

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Workshop Protocol• Entering Workshopg p

– Attendee lines are muted upon entry• Throughout Workshop

– Written questions in Q & A section– Please do not use the chat feature

• Conclusion of Workshop: Q & A SessionConclusion of Workshop: Q & A Session– Use “Raise Hand” feature to ask questions aloud

• Certificate of Completion – 1 AAPC CEU is offered for this course– Certificate of Completion will be sent out to all attendees

2-3 days after workshop based on attendance report2 3 days after workshop based on attendance report• Presentation was sent via email, is also available at

https://www.noridianmedicare.com/dme/train/

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Acronyms• ABN: Advance Beneficiary Notice of Noncoveragey g• CERT: Comprehensive Error Rate Testing• CMS: Center for Medicare & Medicaid Services• DMEPOS: Durable Medical Equipment, Prosthetics,

Orthotics & Suppliespp• IOM: Internet Only Manual• LCD: Local Coverage Determination• Resources

– www.noridianmedicare.com/dme/news/manual/acronyms htmlronyms.html

– www.cms.hhs.gov/apps/acronyms/listall.asp?Letter=ALL


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Agenda

Definition and Purpose

Acceptable ABN

Unacceptable ABN

Completing the ABN

Modifiers

ABNs and Upgrades

Resources and Reminders


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CERT 2012 Improper Payment Rates


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• Written notice of noncoverage• Written notice of noncoverage– Informs beneficiary that Medicare may not

pay for an item– Must be issued before the item/service is

providedprovided• Allows beneficiary to make informed decision

whether to receive the item– Beneficiary liable for payment

Protects supplier from liability• Protects supplier from liability


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Triggering Events

• Initiations– New beneficiary encounter; start of plan of

care; beginning of treatment

• Reductions– Decrease in a component of care

• Terminations– Discontinuation of certain items/services


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Acceptable ABN

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ABN Standards• Must meet readability requirementsy q• Use an approved standard form

– CMS-R-131 (03/11)• Specificity, Delivery and Receipt, Timeliness

– Item must be clearly written W itt i t b fi i th i d– Written in terms beneficiary or authorized representative can understand

– Delivered to beneficiary by qualified notifier before item is furnished• Delivered ABN in person to the beneficiary• Delivered ABN via other means to the

beneficiary


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Voluntary ABN

Statutorily Excluded Items Does not meet definitionStatutorily Excluded Items

• Services with no legal obligation to pay

• Services paid by government entity other th M di

Does not meet definition of a Medicare benefit

• Parenteral/enteral nutrients to treat temporary condition or are administered orally

• Infusion drugs not administered through infusionthan Medicare

• Personal comfort items• Routine physicals and most

screening tests• Bath tub/shower chair• Exercise equipment

administered through infusion pump

• Surgical dressings used to clean wounds or intact skin or provide protection to intact skin

• Irrigation supplies used to irrigate skin or wounds • Exercise equipment

• Telephone communication system (e.g., Life Alert)

• Immunosuppressive drugs used for conditions other than following organ transplants


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ABN-Mandatory Use

S i l d i d f di l it• Services always denied for medical necessity• Frequency limited items• Denial of advance determination of Medicare

coverage (ADMC) • Certain instances of upgrades• No Medicare supplier number • Unsolicited telephone contact made by supplier• Noncontract supplier furnishing DMEPOS inNoncontract supplier furnishing DMEPOS in

competitive bid area (effective 9/4/12)


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Unacceptable ABN

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Unacceptable ABN

• Unreadable or illegible• Unreadable or illegible

• Beneficiary incapable of understanding the ABN

• ABN given to beneficiary during an emergency, under duress, coerced or misled

• ABN delivered to beneficiary more than one year before item was furnished


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Defective Notices

R ti ABN• Routine ABN– No specific, identifiable reason to believe

Medicare will not pay• Generic ABN

– Stating Medicare “may not pay”• Blanket ABN

– Giving ABNs for all items • Signing blank ABNSigning blank ABN

– Obtaining beneficiary signature on blank ABN; completing ABN later


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Completing the ABN

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ABN Instructions

Use ABN form CMS R 131 (03/11)• Use ABN form CMS-R-131 (03/11) www.cms.gov/BNI/Downloads/ABNFormInstructions.zip

• Typed or hand-written on a single page• Blanks (A)-(F), and (H) may be completed prior to

d lidelivery • Verbally review with beneficiary• Deliver in advance• Beneficiary receives a paper copy, notifier keeps

originalg• May include voluntary notification for items that are

not Medicare benefits


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Who May Sign an ABN?• The beneficiary• If beneficiary is incapable or incompetent

– Authorized representative• Individual under state law authorized to make

health decisions – The spouse, unless legally separated– An adult child– A parent– An adult sibling– A close friend

• “An adult who has exhibited special pcare/concern for the beneficiary, who is familiar with the beneficiary’s personal values, and who is reasonably available”


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ABN Header

• Blank ANotifier’s name address telephone n mber– Notifier’s name, address, telephone number

• Blank B– Beneficiary’s name as listed on Medicare card

• Blank CInternal identification number (optional)– Internal identification number (optional)• Cannot use Medicare or social security

number


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ABN Body

Item

ItemItem

•Enter specific item

•Enter frequency and/or duration of item

Enter reason Medicare may not pay for item (be specific)

Enter reasonable estimated cost to the beneficiary


• Reduction in an item/supplies

beneficiary

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ABN Options


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Additional Information and Signature


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Example 1(Section E Needs Improvement)


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Example 2 (Acceptable)


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Example 3 (Acceptable)


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Example 4(Unacceptable—Section E)


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Example 5(Unacceptable—Section E)


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Example 6(Unacceptable—Incomplete,

Signature)Signature)


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Example 7(Unacceptable—Incomplete,

Outdated Form)Outdated Form)


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Other Examples for Section EValid InvalidValid

“The beneficiary does not have the required diagnosis to qualify for this item per the Medicare policy.”

Invalid

“Beneficiary might have similar equipment on file.”

“Medicare may not pay for this item.”

“The beneficiary currently has a standard wheelchair (K0002) paid for by Medicare on 12/2/2009 which is same or similar to

item.

“Beneficiary may not be eligible for Medicare Part B at this time.”

“Not enough supporting this power wheelchair (K0823).”

documentation in the medical record.”


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Financial Liability

• Fail to issue a mandatory ABN

• Issue a defective ABN

• Refund beneficiary in a timely manner

- 30 days after getting the remit- 30 days after getting the remit

- 15 days after determination on an appeal


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Modifiers

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ABN Modifiers – GA and GZ

GA M difi • GZ Modifier• GA Modifier

– Waiver of Liability statement on file

– Supplier expecting

• GZ Modifier– Item or service

expected to deny as not reasonable or necessaryNo ABN obtained

pp p g“not medically necessary” denial

– Mandatory ABN is properly executed

– No ABN obtained– All claim line(s) with

a GZ modifier shall be denied automatically and will not be subject toproperly executed will not be subject to complex medical review


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ABN Modifiers - GY

• Item or service statutorily excluded:– Examples include:

• hearing aids• most dental items• personal comfort items

• Does not meet definition of any Medicare benefit – Examples (not all-inclusive):

• Prosthetic device for temporary conditions• Immunosuppressive drugs used for conditions other than

following Medicare covered transplant g• DME used only outside the home


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ABNs and Upgrades

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ABN Modifiers - Upgrades

GK A t l it d d b h i i• GK – Actual item ordered by physician

• GL – Medically unnecessary upgrade provided instead of standard item, no ABN on file– Supplier not charging for the upgrade


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Upgrades


www.noridianmedicare.com/dme/news/docs/2007/05_may/dme_upgrades.html

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Upgrade: With ABN,Charging Difference to Beneficiary

• ABN must be obtained– Line 1: HCPCS provided with GA– Line 2: HCPCS that meets criteria with GK

• KX if appropriate per policy

– Must bill in this orderMust bill in this order

01 23 10 12 E0265 RR KH GA 1 900 00 1

01 23 10 12 E0260 RR KH KX GK 1 500 00 1


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Upgrade: Provided at No Charge

• Physician ordered upgrade or• Physician ordered upgrade or• Upgrade provided for supplier convenience

– No ABN obtained– Do not bill HCPCS for item provided – Bill HCPCS meeting coverage criteria with GL– KX if appropriate for policy – Item provided must be listed in narrative

01 23 10 12 K0001 RR KH KX GL 1 100 00 1


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Resources and Reminders

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Resources

LCD/P li A ti l• LCD/Policy Article– www.noridianmedicare.com/dme/coverage/lcd.html

• Supplier Manual– www.noridianmedicare.com/dme/news/manual/index.html

• “Dear Physician” letters– www.noridianmedicare.com/dme/coverage/resources.html

• Documentation Checklist– www noridianmedicare com/dme/coverage/checklists html– www.noridianmedicare.com/dme/coverage/checklists.html


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MAC Satisfaction Indicator

• Your opinion counts!

• MSI is a tool that measures your satisfaction with the Medicare claims administrative contractor(s) that serve you( ) y

• Participation is voluntary, but you must register if you would like to take the MSI. A random sample will be drawn from the registry.

• www cms gov/Medicare/Medicare-Contracting/MSI/www.cms.gov/Medicare/Medicare Contracting/MSI/

• Let your voice be heard


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PECOS Requirement

• Claims may be denied if: – The ordering/referring physician is NOT in PECOS and eligible

to order and refer

– The ordering/referring physician is not of the specialty to order/refer

– If the physician's name submitted on the claim does not match their name in PECOS

• Remittance Advice: N544 warning messages

• www.noridianmedicare.com/dme/news/pecos.html– see how to avoid these claim denials by properly submitting the– see how to avoid these claim denials by properly submitting the

ordering physician name from the CMS PECOS Report


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Written Order Prior to Delivery and Face-to-Face Encounter

• Affected DME requires: – Face-to-face evaluation within six months prior to

order• Sooner if required by LCD

• May be performed by MD DO NP PA or CNS• May be performed by MD, DO, NP, PA or CNS

• Must be received by supplier prior to delivery of DME

– WOPD• Detailed written order must be received by the supplier prior to

delivery of DME

NPI must be included on WOPD– NPI must be included on WOPD

• Implemented 7/1/13

• MLN MM8304-RevisedOctober 2013 45Noridian Jurisdiction D DME MAC

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Email Updates

• Tuesday and Friday

• Latest updates and announcements

• Customizable

• Tutorial• Tutorial


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Website Survey


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MREP

M di R it E P i t• Medicare Remit Easy Print– Free software!

– View, search and print remits

– Print and export reports

• CMS Brochure– www.cms.gov/MLNProducts/downloads/MedicareRe

mit_0408.pdf

• MREP Software– www.cms.gov/AccesstoDataApplication/02_Medicare

RemitEasyPrint.asp


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Medicare Learning Network (MLN)

MLN P d t d R G id• MLN Product and Resource Guide– Guides

– Articles

– Educational Tools

– Booklets

– Brochures

– Fact Sheets

– Training Presentations

– Web-Based Training

Special Initiatives– Special Initiatives

– Web Resources

– www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html


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New Recoupment Process

• Suppliers can now elect to have overpayments repaid through “immediate recoupment” process (CR 7688)

• Must submit Request for Immediate qRecoupment Form:– www.noridianmedicare.com/dme/forms/docs/immediate_recoup

ment.pdf

• For more information, see:– www.noridianmedicare.com/dme/news/docs/2012/07_jul/immedi

ate_recoupment_for_claims_overpayments_definition_of_proces

s_suppliers_may_use.html


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Endeavor

Functions• Eligibility

• Claim Status

• Same or Similar

Cl i S ifi R itt

Availability• Eligibility

– 24 hours/day, 7 days/week

• All other functions6 a m 8 p m CT Mon Fri• Claim-Specific Remittance

Advices

• Overpayments

• Reopening/Redetermination– Submission

St t I i

– 6 a.m. – 8 p.m. CT, Mon.– Fri.

– 7 a.m. – 3 p.m. CT, Sat.

– Status Inquiry

• PMD Prior Auth Request Status

Noridian Jurisdiction D DME MAC

www.noridianmedicare.com/dme/claims/endeavor.html

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Education Opportunities

• Web-Based Workshops– Nebulizers

– Medical Review Program

• In-Person Seminars– Sacramento

– Santa Rosa

• DME On Demand

• ACT• ACT– October 17 @ 3 p.m. CT

• www.noridianmedicare.com/dme/trainNoridian Jurisdiction D DME MACOctober 2013 52

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Contact Information

• Supplier Contact Center– 8:00 a.m. – 6:00 p.m. CT M-F

– 1-877-320-0390

• Interactive Voice Response (IVR)p ( )– 24/7 Eligibility

– 6:00 a.m. – 8:00 p.m. CT M-F for claim status

– 1-877-320-0390

• Telephone ReopeningsTelephone Reopenings– 8:00 a.m. – 4:30 p.m. CT M-F

– 1-888-826-5708


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Questions

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Thank you for attending!

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