September 16, 2019

Medicare’s Advanced Beneficiary Notice

Piggy Bank and CoinsMedicare has very specific rules when it comes to their beneficiaries being made aware of their financial responsibility. I find that many physician staff members are confused about how and when the Advanced Beneficiary Notice (ABN) is to be used.

Medicare has identified certain codes that have ‘limited coverage’. ‘Limited coverage’ means that the code is sometimes paid for by Medicare and sometimes not paid for by Medicare due to medical necessity. For codes with ‘limited coverage’ medical necessity may be shown with a diagnosis or a time factor. Some of these codes are only paid for if certain diagnoses are used. If the patient does not have one of the approved diagnoses then Medicare will not pay for that service. Other codes with ‘limited coverage’ are only paid for periodically such as once every 12 or 24 months. If the appropriate time has not passed, Medicare will not pay for the service as it is too soon to have this service repeated as far as they are concerned. For example, Medicare will pay for a well woman once every 12 months if the patient is considered ‘high risk’ by Medicare. If the patient is not considered ‘high risk’ then Medicare will pay for this service once every 24 months. If you repeat this service, even 1 month, too soon Medicare will not pay.

Medicare has provided physicians with two Advanced Beneficiary Notices. One is the general ABN and the other is for laboratory services. These forms must be filled out by the physician’s office and signed by the patient PRIOR to the patient receiving the service. If this form is not filled and signed prior to the service the physician may not ask for payment from the Medicare beneficiary. Basically, the physician just performed the service at ‘no charge’ to anyone. The patient will not be responsible because they were not educated concerning their financial responsibility before the service was performed and Medicare will not pay if they do not consider the service medically necessary.

The physician can only ask the patient to sign the ABN if necessary. Your office cannot have every Medicare patient who walks thru the door sign the ABN ‘just in case’. Medicare considers this abuse. Remember that the ABN must be filled out by your office before you ask the patient to sign. The form has a place for you to describe what the service is and why Medicare is not expected to pay for it. If these two areas are not filled out before you ask the patient to sign then you are not using the forms properly and can be sited for abuse.

If the patient signs the ABN and is made aware of their financial responsibility you may require the patient to pay for this service on the date the service is provided. You may also charge the patient 100% of your fee. You do not have to reduce your charge to the Medicare allowable.

When billing a service to Medicare that you have obtained an ABN for you should attach the –GA, -GY, or –GZ modifier to the charge. These modifiers let Medicare know that you have a waiver in place for this service. When the patient receives the MEOB it will show your fee for this service as the patient’s responsibility to pay. If you fail to include one of these modifiers the MEOB will show that it is not the patient’s responsibility to pay and the patient will want a refund if they have already paid you.

Keep in mind that physicians and Medicare very often have different thoughts about medical necessity. When it comes to the Medicare reimbursement a practice has to be concerned with what Medicare considers medically necessary so that the proper forms can be obtained to insure your right to collect from the patient.

Medicare’s Smoking and Tobacco Use Cessation Benefit

Over 400,000 smokers die each year from smoke related diseases. About 300,000 of those are Medicare patients age 65 and older. Research shows that about 10% of the total program costs for Medicare for 1997 were related to smoking. The U.S. Surgeon General has reported that quitting smoking leads to significant risk reduction and other health benefits even in older people who have smoked for years.

Medicare has a benefit that began on March 22, 2005 that can help beneficiaries ‘kick the habit’. This benefit is available to beneficiaries who have an illness caused by or complicated by tobacco use. These illnesses make up the bulk of the Medicare expenditures today, according to Medicare. Beneficiaries who take medication whose effectiveness is complicated by tobacco use are eligible for this benefit. Medications including insulin and some meds used to treat high blood pressure, blood clots and depression are examples. Illnesses such as heart disease, cerebrovascular disease, multiple cancers, lung disease, weak bones, blood clots and cataracts are examples of those that can get coverage for smoking and tobacco use cessation.

Medicare pays for two cessation attempts per year. Each attempt includes four intermediate (3-10 minutes each) or intensive sessions (longer than 10 minutes each) up to eight sessions in a twelve month period. Medicare recognizes HCPCS codes G0375 and G0376 for these visits. The diagnoses are carrier specific. The co-pay/co-insurance and deductible do apply for this benefit.

Your office may be losing out on some reimbursement if you are performing theses services and not charging Medicare for them. HCPCS code G0375 will reimburse from about $11.00 up to over $13.00, depending on the locality, for the 3-10 minute counseling session. G0376 reimburses between $21.00 and $28.00, depending on the locality, for a counseling session over 10 minutes. Physicians and other Medicare-recognized providers can provide these counseling services.

PMI’s 2007 Conference for Medical Office Professionals

Practice Management Institute LogoThe healthcare industry is constantly changing and each New Year brings new challenges. Take your practice to the next level by attending Practice Management Institute’s 2007 Conference for Medical Office Professionals in exciting Las Vegas.

We offer 14 general and breakout sessions concerning reimbursement and management issues. Plan to customize your agenda and get the information that pertains especially to you and your practice. You will have access to some of the top leaders in the national education industry and walk away with valuable tips and tools designed to help boost your bottom line.

This conference offers advanced learning for medical office professionals. PMI’s certified professionals can plan to get all of the 12 CEUs necessary to renew your certification in this exclusive two-day event.

Don’t miss out on this exciting educational event! The PMI conference will be held at the Palace Station near the fabulous Las Vegas Strip. You will leave this conference with the knowledge to ensure your practice is getting every dime it is legally entitled to.

I look forward to seeing you there!

E/M Code 99211

Prior to 1998, 99211 was the most under used code in this country. This is no longer the case. Many physician offices are using this code commonly referred to as a ‘nurses visit’. Many insurance carriers are watching this code. Before entering this code on the claim form be sure the documentation is correct. Common problems with the documentation are no chief complaint, no review of systems, or no plan of treatment. In some cases, medical necessity is not even established.

Documentation for the 99211 should include the rationale for ordering tests, past and present diagnoses, health risk factors, patient’s progress and response to treatment, any changes in the treatment plan, and revision of diagnosis.

PQRI — Are You Cashing In?

Physician Quality Reporting Initiative (PQRI) is an incentive offered by Medicare to Medicare providers. PQRI will focus attention on quality of care. This program is paving the way for Pay for Performance.

Providers will use Category II codes, modifiers and temporary G-codes to report 74 unique measures associated with clinical conditions that are routinely represented on Medicare Fee for Service claims. The measures address various aspects of quality of care associated with prevention, chronic care management, acute episode of care management, procedural related care, resource utilization, and care coordination.

Some measures have a Performance Timeframe (i.e., perform within 12 months) that may be distinct from the Reporting Frequency (i.e., report 1 time only). If four or more measures are applicable for the practice, the provider must report at least 3 of them correctly for at least 80% of the cases (visits or patients). If 3 measures or less are applicable, the provider must report all of them correctly for at least 80% of the cases.

PQRI begins with services performed on July 1, 2007 thru December 31, 2007. Providers that report successfully are eligible for a 1.5% bonus subject to a cap. The bonus is calculated using total allowed charges for Medicare covered professional services furnished during the reporting period. All claims for services performed during these dates must be submitted to Medicare by February 29, 2008 to be considered. The bonus payment will be made next summer.

Providers wishing to participate in the PQRI need not register. All you do is begin reporting for services performed beginning July 1st. You must be a Medicare provider and use your individual NPI on your claims to be eligible to participate.

To find out more, visit the PQRI website.

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