Advance Beneficiary Notices Wisconsin Health Information ...

Advance Beneficiary NoticesAdvance Beneficiary Notices

Wisconsin Health Information Wisconsin Health Information Management AssociationManagement Association

September 13, 2002September 13, 2002

Presented by:Presented by:

Richard Donkle, CPARichard Donkle, CPA

Rural Wisconsin Health CooperativeRural Wisconsin Health Cooperative

Advance Beneficiary Notices Advance Beneficiary Notices (ABNs)(ABNs)

Advise Medicare beneficiariesAdvise Medicare beneficiaries Issued before items or services are furnishedIssued before items or services are furnished Issued when Medicare is likely to deny paymentIssued when Medicare is likely to deny payment


New ABNsNew ABNsCMS published in June 2002CMS published in June 2002CMS-R-131CMS-R-131

General Use (ABN-G)General Use (ABN-G)Laboratory Tests (ABN-L)Laboratory Tests (ABN-L)


New ABNs (continued)New ABNs (continued)May not be modifiedMay not be modifiedContain customizable boxesContain customizable boxes


ABNs are issued when Medicare probably or ABNs are issued when Medicare probably or certainly will not pay for an item or service certainly will not pay for an item or service on the basis of one of the following on the basis of one of the following statutory exclusions:statutory exclusions:

Section 1862(a)(1) of the ActSection 1862(a)(1) of the Act Section 1834(a)(17)(B) of the ActSection 1834(a)(17)(B) of the Act Section 1834(j)(1) of the ActSection 1834(j)(1) of the Act Section 1834(a)(15) of the ActSection 1834(a)(15) of the Act


ABNs are issued when Medicare probably or certainly will ABNs are issued when Medicare probably or certainly will not pay for an item or service on the basis of one of the not pay for an item or service on the basis of one of the following statutory exclusions (continued):following statutory exclusions (continued):

Section 1862(a)(9) of the ActSection 1862(a)(9) of the Act Section 1879(g)(1) of the ActSection 1879(g)(1) of the Act Section 1879(g)(2) of the ActSection 1879(g)(2) of the Act


Section 1862(a)(1), lack of medical necessity, Section 1862(a)(1), lack of medical necessity, exclusions include:exclusions include:

Custodial CareCustodial Care MammographyMammography Pap smearPap smear Pelvic examPelvic exam GlaucomaGlaucoma Prostate cancerProstate cancer Colorectal cancer screening testsColorectal cancer screening tests


Section 1834(a)(17)(B) addresses violation of Section 1834(a)(17)(B) addresses violation of the prohibition on unsolicited telephone the prohibition on unsolicited telephone contacts for medical equipment and suppliescontacts for medical equipment and supplies


Section 1834(j)(1) addresses situations where Section 1834(j)(1) addresses situations where medical equipment and supplies suppler medical equipment and supplies suppler number requirements are not metnumber requirements are not met


Section 1834(a)(15) addresses situations Section 1834(a)(15) addresses situations where medical equipment and/or supplies where medical equipment and/or supplies are denied in advanceare denied in advance


Section 1862(a)(9) addresses custodial careSection 1862(a)(9) addresses custodial careSection 1879(g)(1) concerns homebound and Section 1879(g)(1) concerns homebound and

intermittent denials for home health careintermittent denials for home health careSection 1879(g)(2) addresses items or services Section 1879(g)(2) addresses items or services

provided to a hospice patient who is not terminally provided to a hospice patient who is not terminally illill


Use of Condition Codes (Part A):Use of Condition Codes (Part A): 21 - Item or service is non-covered, but a denial is 21 - Item or service is non-covered, but a denial is

sought in order to bill other insurance (ABN not sought in order to bill other insurance (ABN not required)required)

20 – Used in a demand bill situation, when an ABN 20 – Used in a demand bill situation, when an ABN has been issued, but beneficiary still wants Medicare has been issued, but beneficiary still wants Medicare billedbilled


Use of Modifiers (Part B):Use of Modifiers (Part B): GA - ABN on fileGA - ABN on file GZ - Item or service expected to be denied as not GZ - Item or service expected to be denied as not

reasonable and necessary (No signed ABN on file)reasonable and necessary (No signed ABN on file) GY - Item or service statutorily excluded or does GY - Item or service statutorily excluded or does

not meet the definition of any Medicare benefitnot meet the definition of any Medicare benefit


ABNs are not necessary for specifically excluded items or services.ABNs are not necessary for specifically excluded items or services.

Excluded items include:Excluded items include: Personal comfort itemsPersonal comfort items Most shots (vaccinations)Most shots (vaccinations) Hearing aids and hearing examinationsHearing aids and hearing examinations


Excluded items include (continued):Excluded items include (continued): Most outpatient prescription drugsMost outpatient prescription drugs Orthopedic shoes and foot supports (orthotics)Orthopedic shoes and foot supports (orthotics) Health care received outside of the USHealth care received outside of the US Services required as a result of warServices required as a result of war Services paid for by a government entity that is not MedicareServices paid for by a government entity that is not Medicare


Excluded items include (continued):Excluded items include (continued): Services for which the patient has no obligation to Services for which the patient has no obligation to

paypay Home health services furnished under a plan of Home health services furnished under a plan of

care, if the agency does not submit the claimcare, if the agency does not submit the claim Items and services excluded under the Assisted Items and services excluded under the Assisted

Suicide Funding Restriction Act of 1997Suicide Funding Restriction Act of 1997


Excluded items include (continued):Excluded items include (continued): Items or services furnished in a competitive Items or services furnished in a competitive

acquisition area by any entity that does not have a acquisition area by any entity that does not have a contract with the Department of Health and contract with the Department of Health and Human Services (except in a case of urgent need)Human Services (except in a case of urgent need)

Physicians’ services performed by a physician Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless anesthetist, when furnished to an inpatient, unless they are furnished under arrangements by the they are furnished under arrangements by the hospitalhospital


Excluded items include (continued):Excluded items include (continued): Items and services furnished to an individual who is a resident 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 of a SNF, or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNFthey are furnished under arrangements by the SNF

Services of an assistant at surgery without prior approval from Services of an assistant at surgery without prior approval from the peer review organizationthe peer review organization


Excluded items include (continued):Excluded items include (continued): Outpatient occupational and physical therapy services furnished Outpatient occupational and physical therapy services furnished

incident to a physicians’ servicesincident to a physicians’ services Routine physicals and most tests for screeningRoutine physicals and most tests for screening Routine eye care, eyeglasses and examinationsRoutine eye care, eyeglasses and examinations Cosmetic surgeryCosmetic surgery


Excluded items include (continued):Excluded items include (continued): Dental care and dentures (in most cases)Dental care and dentures (in most cases) Routine foot care and flat foot careRoutine foot care and flat foot care Services by immediate relativesServices by immediate relatives Services under a physicians’ private contractServices under a physicians’ private contract


Examples of appropriate uses:Examples of appropriate uses: Magnetic Resonance Angiography (MRA) to rule out Renal Artery Magnetic Resonance Angiography (MRA) to rule out Renal Artery

Stenosis – this is not a covered indication for MRA per Coverage Stenosis – this is not a covered indication for MRA per Coverage Issues Manual (CIM) 50-14Issues Manual (CIM) 50-14

Hyperbaric Oxygen (HBO) treatments for a non-healing venous Hyperbaric Oxygen (HBO) treatments for a non-healing venous stasis ulcer – this is not a covered indication for HBO per CIM 35-10stasis ulcer – this is not a covered indication for HBO per CIM 35-10


Examples of appropriate uses (continued):Examples of appropriate uses (continued): Screening Mammography less than one year since Screening Mammography less than one year since

the lastthe last An experimental procedure, eg. Vagal Nerve An experimental procedure, eg. Vagal Nerve

Stimulation (VNS) for Refractory DepressionStimulation (VNS) for Refractory Depression An item or service which is not reasonable & An item or service which is not reasonable &

necessary per a Local Medical Review Policy necessary per a Local Medical Review Policy (LMRP), e.g. IV levocarnitine given to a dialysis (LMRP), e.g. IV levocarnitine given to a dialysis patient (see UGS LMRP INJ-101)patient (see UGS LMRP INJ-101)


Examples of inappropriate or unnecessary use:Examples of inappropriate or unnecessary use: ER patient prior to medical screening examER patient prior to medical screening exam Any patient “under duress”Any patient “under duress” Excluded routine screening tests, e.g. cholesterol Excluded routine screening tests, e.g. cholesterol

testing without symptoms or history of testing without symptoms or history of hypercholesterolemiahypercholesterolemia


Examples of inappropriate or unnecessary use Examples of inappropriate or unnecessary use (continued):(continued):

Cosmetic surgery Cosmetic surgery Hearing aidsHearing aids Tooth extractionTooth extraction


For additional information go to:For additional information go to:

http://www.cms.gov/medicare/bni/http://www.cms.gov/medicare/bni/

Advance Beneficiary NoticesAdvance Beneficiary Notices

Wisconsin Health Information Wisconsin Health Information Management AssociationManagement Association

September 13, 2002September 13, 2002

Presented by:Presented by:

Richard Donkle, CPARichard Donkle, CPA

Rural Wisconsin Health CooperativeRural Wisconsin Health Cooperative

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