|
|
|
New Procedures for Using the
ABN Form (*) Reprinted from Palmetto
GBA
The purpose of an ABN is to inform the beneficiary that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay for the item or service under different circumstances. This allows the beneficiary to make an informed consumer decision about whether or not to receive the items or services for which s/he may have to pay out of pocket or through other insurance. DMEPOS suppliers have been using an ABN form (HCFA-R-131) when they expect that Medicare may not pay for an item. The Office of Management and Budget (OMB) recently cleared a new, optional ABN form (CMS-R-131-G) that you can use for the same purpose. This form is available online at: http://www.hcfa.gov/medicare/bni/. For example, you may believe that the DMERC will deny an item as not medically necessary, or that the quantities of an item exceed the quantity that Medicare allows. On the ABN, you must explain why Medicare will deny the specific item in terms the beneficiary can understand. You may not simply give ABNs to every Medicare beneficiary you serve, unless there is a specific reason why you feel Medicare will deny payment (e.g., you only sell items that Medicare never covers). Statements such as "I never know when Medicare will pay" are not acceptable on ABNs. ABNs for Upgrades Medicare will accept ABNs on upgrades. For Medicare purposes, CMS defines an upgrade as an item that is more expensive, contains more components or features, or is greater in quantity than what the physician ordered. The upgraded item may be from one HCPCS code to another, or within the same HCPCS code. However, the upgraded item must be within the range of services that are appropriate for the beneficiary's medical condition. For example, the beneficiary can upgrade from a standard manual wheelchair to an ultralight wheelchair, but not from a cane to a wheelchair. Whether or not to upgrade is the beneficiary's choice. CMS does not include items that a physician ordered, but which the supplier believes to be more than what Medicare considers medically necessary. You may still use an ABN in this situation, but must continue to follow the current operating procedures for ABNs that are already in place, and bill them as you have billed them in the past (i.e., bill the item that the physician ordered on one line with the GA modifier). If a beneficiary agrees to be financially liable by signing an ABN, you may collect the difference between the charges for the upgraded item and the charges for the non-upgraded item from the beneficiary. In some cases, you may choose to provide a free upgrade for a beneficiary (e.g., to lower costs by maintaining an inventory of only one type of manual wheelchair that can supply all of your manual wheelchair needs). When providing a free upgrade, you should not have the beneficiary sign an ABN, because you will not be charging more than the normal deductible and co-payment for the non-upgraded item. ABNs for upgrades can apply to both assigned and unassigned claims. Filing Claims When ABN Is Used for Upgrades To provide a free upgrade: Use the appropriate HCPCS code for the non-upgraded item that the physician ordered. You must only charge for the non-upgraded item. Use a GL modifier with the HCPCS code. In Item 19 of the claim, or as an attachment to the claim, specify the make and model of the upgraded item you actually furnished, and describe why this item is an upgrade (e.g., you provided an ultralight wheelchair when the physician ordered a standard wheelchair). Electronic media claim filers should use the HA0 record for this purpose. To charge for the difference between the Medicare allowable for a non-upgraded item and an upgrade: List two lines on your claim. On the first line, list the upgraded item with a GA or GZ modifier. Use the GA modifier if the beneficiary signed an ABN, and the GZ modifier if the beneficiary did not sign an ABN. A certificate of medical necessity (CMN) is not required for this item. On the second line, list the item the physician actually ordered. A CMN is required for this item. Use a GK modifier on this line. If you are upgrading from one item to another within the same HCPCS code, this will be the same HCPCS code you put on line one, but with a different charge amount. You must indicate the full charge for each item on the claim form, not the difference between the two. You may include more than one upgraded item on a claim. However, for items where you provide an upgrade, you must list the non-upgraded item on the line immediately following the upgraded item. The following are examples on how to file claims with an ABN and without an ABN:
|
|||||||||||||
|
