Piedmont Access To Health Services, Inc.

Policy Number: 01-02-036

SUBJECT: Use of ABNs

EFFECTIVE DATE: 07/5/2012

REVIEW/REVISED: 10/14/2013, 11/10/2014, 11/11/2015, 03/21/2016

POLICY: PATHS recognizes that the C M S-R-131 (or known as ABN) , is a standardized notice that a health care provider/supplier or his/her designee must give to a Medicare beneficiary, before providing certain Medicare Part B (outpatient) or Part A (limited to hospice and Religious Nonmedical Healthcare Institutions only) items or services. The ABN must be issued when the health care provider believes that Medicare may not pay for an item or service that Medicare usually covers because it is not considered medically reasonable and necessary for this patient in this particular instance.

ABNs are only provided to beneficiaries enrolled in Original (Fee-For-Service) Medicare. The

ABN allows the beneficiary to make an informed decision about whether to receive services

and accept financial responsibility for those services if Medicare does not pay. The ABN serves

as proof that the beneficiary had knowledge prior to receiving the service that Medicare might

not pay. If a health care provider/supplier does not deliver a valid ABN to the beneficiary when

required by statute, the beneficiary cannot be billed for the service and the provider may be held financially liable.

ABN also serves as an optional notice that providers/suppliers may use to forewarn beneficiaries of their financial liability prior to providing care that Medicare never covers. ABN issuance is not required in order to bill a beneficiary for an item or service that is not a Medicare and thus, never covered.

PROTOCOL:

  1. It is important to understand the following when dealing with the need to provide an ABM:
  2. Medical Necessity: Medical necessity is defined as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.
  3. ICD-10-C M Coding: All services reported to the Medicare Program by a physician or non-physician practitioner must demonstrate medical necessity through the use of International Classification of Diseases, Clinical Modification (ICD-10-C M) diagnostic coding carried to the highest level of specificity for the date of service.
  4. Definition of Limited Coverage: Coverage of certain items/services is limited by the diagnosis. If the diagnosis listed on the claim is not the same as one of those listed as covered for the item/service, the procedure is denied.

d.  Limited coverage may be the result of National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The Medicare Coverage Database (MCD) at http://www.cms. gov/medicare-coverage-database/overview-and-quick-search.aspx contains all NCDs and LCDs, local policy articles, and proposed NCD decisions. NCDs are published at http://www.cms.gov/ Manuals/IOM/list.asp on the CMS website. The official versions of LCDs may be viewed by contractor, state, or alphabetically at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx> on the CMS website.

  1. Health care providers and suppliers are expected to be aware of considered reasonable, medically necessary, and appropriate. In most cases, the availability of this information indicates that the health care provider knew, or should have known, the item/service would be denied as not medically necessary. As such a patient should be given an ABN.
  2. KEY POINTS FOR HEALTH CARE PROVIDERS.
  3. The provider/supplier must issue an ABN to the beneficiary prior to providing care that may not be covered by Medicare because it is not medically reasonable and necessary in this particular case.
  4. After the beneficiary signs a properly issued ABN indicating his/her choice to receive the item or service and accept financial liability, the provider/supplier is permitted to bill the beneficiary for the care.
  5. If an ABN is not issued or found to be an invalid notice in a situation where notice is required, the provider/supplier is not permitted to bill the beneficiary for the services, and the provider/supplier may be held liable if Medicare does not pay.
  6. Health care providers/suppliers are not permitted to use ABNs to charge a beneficiary for a component of a service when full payment is made through a bundled payment.
  7. Providers and suppliers are prohibited from using an ABN to transfer liability to the beneficiary when items and services would otherwise be paid for by Medicare.
  8. Mandatory ABN Uses:
  9. An ABN must be given when Medicare is expected to deny payment (entirely or in part) for the item or service because it is not reasonable and necessary under Medicare Program standards or because it is considered custodial care.
  10. Common reasons for an item or service being denied as not medically reasonable and necessary include that the care:
  11. Is experimental and investigational;
  12. Is not indicated for diagnosis and/or treatment in this case;
  13. Is not considered safe and effective; or
  14. Exceeds the number of services that Medicare allows in a specific time period for the corresponding diagnosis.
  15. Durable Medical Equipment (DME) suppliers have additional mandatory requirements.
  16. Issue an ABN before providing the beneficiary with items/services if:
  17. The provider has violated the prohibition against unsolicited telephone contacts;
  18. The supplier has not met supplier number requirements;
  19. The supplier is a noncontract supplier providing an item listed in a competitive bidding area; or
  20. An advance coverage determination is required.
  21. ROUTINE NOTICE PROHIBITION: Health care providers/suppliers are prohibited from issuing ABNs on a routine basis (i.e., where there is no reasonable basis for Medicare to not cover). Providers and suppliers must be sure that there is a reasonable basis for non-coverage associated with the issuance of each ABN. Some situations may require a higher volume of ABN issuance, and as long as there is proper evidence for ABN use, the provider will not have violated the routine notice prohibition.
  22. Examples of Medicare Program exclusions are:
  23. Personal comfort items;
  24. Self-administered drugs and biologicals (i.e., pills and other medications not administered by injections);
  25. Cosmetic surgery (unless required for prompt repair of accidental injury or for improvement of a malformed body member);
  26. Eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses in the absence of disease or injury to the eye;
  27. Routine immunizations (except influenza, pneumococcal, and hepatitis B vaccinations; these services have specific regulations regarding beneficiary responsibility);
  28. Physicals, laboratory tests, and X-rays performed for screening purposes (except screening mammograms, screening Pap smears, and various other mandated screening services; these services have specific guidelines regarding beneficiary responsibility and when an ABN should be obtained);
  29. X-rays and physical therapy provided by chiropractors;
  30. Hearing aids and hearing examinations;
  31. Routine dental services (i.e., care, treatment, filling, removal, or replacement of teeth);
  32. Supportive devices for the feet;
  33. Routine foot care (i.e., cutting or trimming corns or calluses, unless inflamed or infected;

routine hygiene or palliative care or trimming of nails);

  1. Services furnished or paid by government institutions;
  2. Services resulting from acts of war; and
  3. Charges made to the Medicare Program for services furnished by a physician or supplier to his/her immediate relatives or members of his/her household. The following relationships are included in the definition of immediate relative: husband and wife; natural parent, child, and sibling; adopted child and adoptive parent; adopted sibling; stepparent, stepchild, stepbrother, and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law; grandparent and grandchild; and spouse of grandparent or grandchild. By definition, members of the household include those persons sharing a common abode with the physician as part of a single-family unit, including those related by blood, marriage, or adoption; domestic employees; and others who live together as part of a single-family unit.
  4. The ABN should be given to:
  5. The Medicare beneficiary; or
  6. The Medicare beneficiary’s representative for the purposes of receiving notice under applicable state or other law.

SIGNATURES:

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Chief Executive Officer Date

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Chief Operating Officer Date

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Chief Medical Officer Date

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Director of Nursing and Quality Date

01-02-036 Use of ABNs

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01-02-036 Use of ABNs

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