Health Information Management

Follow ABN guidelines for noncovered outpatient procedures

APCs Insider, May 12, 2006

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Follow ABN guidelines for noncovered outpatient procedures

QUESTION: When a Medicare beneficiary presents for an outpatient procedure that we know is noncovered by Medicare, can we ask the patient for payment at the time of the service? If so, can we ask the patient to make a full payment? What about for a procedure that might not be covered and for which we deliver an advanced beneficiary notice (ABN)? Can we collect any payment at the time of service?

ANSWER: Medicare does not require providers to issue an ABN for services that are "statutorily excluded" (services that are never a Medicare benefit). However, you may still want the patient to sign a waiver of liability to ensure that they understand that they are responsible for the charges. For an excluded service, you can collect full payment for the services and, if it is your usual practice, you may request payment at the time of service.

If Medicare covers the service and the patient completes an ABN, you may collect payment from the patient at the time of service. If Medicare pays for the service, you must make the appropriate refund. If the service may be covered and you do not require the patient to complete an ABN, you cannot bill the patient.

Be sure to use any applicable condition codes and/or modifiers (e.g., -GA, -GX, -GZ) on the UB-92 or CMS-1500 form.

Go to the Trailblazer Health Web site at http://www.trailblazerhealth.com/parta/downloads/abn_for_basics.pdf for a helpful flow chart that can help with the process.



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