Advance Beneficiary Notices

1. Advance Beneficiary Notices Wisconsin Health Information Management Association September 13, 2002 Presented by: Richard Donkle, CPA Rural Wisconsin Health Cooperative

2. Advance Beneficiary Notices (ABNs) • Advise Medicare beneficiaries • Issued before items or services are furnished • Issued when Medicare is likely to deny payment

3. Advance Beneficiary Notices (ABNs) New ABNs • CMS published in June 2002 • CMS-R-131 • General Use (ABN-G) • Laboratory Tests (ABN-L)

4. Advance Beneficiary Notices (ABNs) New ABNs (continued) • May not be modified • Contain customizable boxes

5. Advance Beneficiary Notices (ABNs) 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: • Section 1862(a)(1) of the Act • Section 1834(a)(17)(B) of the Act • Section 1834(j)(1) of the Act • Section 1834(a)(15) of the Act

6. Advance Beneficiary Notices (ABNs) 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): • Section 1862(a)(9) of the Act • Section 1879(g)(1) of the Act • Section 1879(g)(2) of the Act

7. Advance Beneficiary Notices (ABNs) Section 1862(a)(1), lack of medical necessity, exclusions include: • Custodial Care • Mammography • Pap smear • Pelvic exam • Glaucoma • Prostate cancer • Colorectal cancer screening tests

8. Advance Beneficiary Notices (ABNs) Section 1834(a)(17)(B) addresses violation of the prohibition on unsolicited telephone contacts for medical equipment and supplies

9. Advance Beneficiary Notices (ABNs) Section 1834(j)(1) addresses situations where medical equipment and supplies suppler number requirements are not met

10. Advance Beneficiary Notices (ABNs) Section 1834(a)(15) addresses situations where medical equipment and/or supplies are denied in advance

11. Advance Beneficiary Notices (ABNs) Section 1862(a)(9) addresses custodial care Section 1879(g)(1) concerns homebound and intermittent denials for home health care Section 1879(g)(2) addresses items or services provided to a hospice patient who is not terminally ill

12. Advance Beneficiary Notices (ABNs) Use of Condition Codes (Part A): • 21 - Item or service is non-covered, but a denial is sought in order to bill other insurance (ABN not required) • 20 – Used in a demand bill situation, when an ABN has been issued, but beneficiary still wants Medicare billed

13. Advance Beneficiary Notices (ABNs) Use of Modifiers (Part B): • GA - ABN on file • GZ - Item or service expected to be denied as not reasonable and necessary (No signed ABN on file) • GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit

14. Advance Beneficiary Notices (ABNs) ABNs are not necessary for specifically excluded items or services. Excluded items include: • Personal comfort items • Most shots (vaccinations) • Hearing aids and hearing examinations

15. Advance Beneficiary Notices (ABNs) Excluded items include (continued): • Most outpatient prescription drugs • Orthopedic shoes and foot supports (orthotics) • Health care received outside of the US • Services required as a result of war • Services paid for by a government entity that is not Medicare

16. Advance Beneficiary Notices (ABNs) Excluded items include (continued): • Services for which the patient has no obligation to pay • Home health services furnished under a plan of care, if the agency does not submit the claim • Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997

17. Advance Beneficiary Notices (ABNs) Excluded items include (continued): • 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) • 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

18. Advance Beneficiary Notices (ABNs) Excluded items include (continued): • 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 • Services of an assistant at surgery without prior approval from the peer review organization

19. Advance Beneficiary Notices (ABNs) Excluded items include (continued): • Outpatient occupational and physical therapy services furnished incident to a physicians’ services • Routine physicals and most tests for screening • Routine eye care, eyeglasses and examinations • Cosmetic surgery

20. Advance Beneficiary Notices (ABNs) Excluded items include (continued): • Dental care and dentures (in most cases) • Routine foot care and flat foot care • Services by immediate relatives • Services under a physicians’ private contract

21. Advance Beneficiary Notices (ABNs) Examples of appropriate uses: • 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 • Hyperbaric Oxygen (HBO) treatments for a non-healing venous stasis ulcer – this is not a covered indication for HBO per CIM 35-10

22. Advance Beneficiary Notices (ABNs) Examples of appropriate uses (continued): • Screening Mammography less than one year since the last • An experimental procedure, eg. Vagal Nerve Stimulation (VNS) for Refractory Depression • 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)

23. Advance Beneficiary Notices (ABNs) Examples of inappropriate or unnecessary use: • ER patient prior to medical screening exam • Any patient “under duress” • Excluded routine screening tests, e.g. cholesterol testing without symptoms or history of hypercholesterolemia

24. Advance Beneficiary Notices (ABNs) Examples of inappropriate or unnecessary use (continued): • Cosmetic surgery • Hearing aids • Tooth extraction

25. Advance Beneficiary Notices (ABNs) For additional information go to: http://www.cms.gov/medicare/bni/

26. Advance Beneficiary Notices Wisconsin Health Information Management Association September 13, 2002 Presented by: Richard Donkle, CPA Rural Wisconsin Health Cooperative