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Q: If a service is known to be noncovered because of the status indicator E, would we issue an ABN to the patient? Or is there another form indicating noncoverage we should issue the patient?

Patient Financial Services Weekly Advisor, April 29, 2005

A: Whether required to provide an Advance Beneficiary Notice (ABN), hospital ABN (HABN), home health ABN (HHABN) or Notice of Exclusion from Medicare Benefits (NEMB), the purpose is the same; advise beneficiaries, before items or services are furnished, when Medicare is likely to deny reimbursement.

Beneficiary notices facilitate informed consumer decisions regarding receipt of items or services for which out-of-pocket payment is likely. Advance notice regarding coverage is believed to enable healthcare consumers to become more active participants in treatment decisions.

Status indicator E represents noncovered items and services; codes not payable in the hospital outpatient setting; and codes not recognized by OPPS but for which an alternate code may be applicable.

For status indicator E radiology services not payable in the outpatient setting, an ABN is appropriate as long as the service is provided on an outpatient basis.

When a code is not allowed in a hospital outpatient setting, it is important to be sure it is the only code available to accurately represent the service.

For services never considered a Medicare benefit, an NEMB is used.

For inpatient services that are not covered, an HABN is appropriate.

This question was answered by Barbara Aubry, RN, CCM, CPC, CHCQM, healthcare policy specialist at 3M HIS @ Rockleigh.

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