It’s time to review Medicare guidelines and train staff

For many orthopaedic offices, it is standard practice to require Medicare beneficiaries to sign a blank advance beneficiary notice (ABN) at check-in, “just in case” the physician recommends an item or service that may not be covered by Medicare. The rationale is that the team can fill in the blanks later as documentation that the patient was told he or she is responsible for payment.

If this is how your team handles ABNs, it is time to reset your systems.

Blank forms are a no-no

“We frequently observe staff issuing blank ABNs [for] all Medicare patients,” said Cheyenne Brinson, MBA, CPA, consultant and speaker with KarenZupko & Associates, Inc. (KZA). “But Medicare has explicitly said that handing over a blank form is not the proper intent or use of this form.”

The purpose of the ABN, Ms. Brinson clarified, is to notify a patient when the physician is recommending an item or service that Medicare may not cover because it does not meet medical necessity criteria, it is a noncovered service, or it is considered by Medicare to be experimental or investigational. In orthopaedics, ABNs are commonly used for certain durable medical equipment (DME) and injections and physical therapy visits that exceed the therapy cap.

“When staff fill in the details on a presigned ABN after the patient visit, your practice has not complied with the intent to notify,” Ms. Brinson explained, “because the patient has not been educated and informed about his or her choice or financial responsibility.”

“‘But we’re busy, and it’s easier.’ We hear this a lot from staff,” said Amy Boyer, MBA, consultant and speaker with KZA. “They get busy and figure it’s easier to just give a blank ABN to every Medicare [beneficiary].” Although it may achieve the purpose of getting the ABN signed, Ms. Boyer said this practice just isn’t right.

“The intent of the ABN is price transparency,” she said. “The Medicare population is less likely to understand the nuances of what they owe, and signing a blank form doesn’t provide the information they need about the services for which they may be billed.”

How to do ABNs right

If your practice is doling out blank ABNs, “Stop now, reset, and retrain,” Ms. Brinson recommended. “Review Medicare guidelines, train staff on correct intent and use, and only ask patients to sign an ABN after staff have completed it with the specific recommended service and reviewed it with patients.” The Medicare Learning Network website has a guide for the correct use of ABNs. Table 1 includes some of the guide’s basic information on when to use an ABN.

For example, platelet-rich plasma (PRP) injections are not covered by Medicare and require an ABN. Medicare considers these injections experimental and investigational, so staff should complete an ABN form to indicate this, along with the cost, and review the form with the patient.

“The patient should be asked to sign, indicating they understand that the responsibility for payment is theirs, should they choose to have the injection,” Ms. Brinson said. For more information on when PRP is reportable, see “PRP Gets CPT Category III Code,” AAOS Now, August 2010.

“The conversation is best held in the clinical setting, when treatment is being recommended,” added Ms. Boyer. “For efficiency, create premade ABNs for services you recommend regularly. Include the service, such as PRP injection, the reason it might not be covered, and the cost. For each patient, clinical staff need only fill in the patient name and beneficiary number.”

For an even faster workflow, Ms. Boyer suggested configuring ABNs in the electronic health record (EHR). “Once the ABN is loaded, it can be pulled up while you are in the patient’s account and printed for discussion. The patient simply reviews and signs it.”

Medicare also requires an ABN when an item or service may not be covered; for example, trigger point injections. Coverage of these injections is determined by the carrier’s local coverage determination (LCD) policy.

“Your LCD policy might state that the payer covers these injections if certain medical necessity criteria are met, including the use of designated diagnoses,” explained Sarah Wiskerchen, MBA, CPC, consultant and coding educator with KZA. “If the physician recommends a trigger point injection for a diagnosis that’s not on the LCD’s approved diagnosis list, that’s when you must use an ABN. You are basically telling the patient, ‘We have reason to believe Medicare will not cover the injection for this diagnosis, and you will be responsible financially if Medicare doesn’t pay.’”

It’s important to recognize that an LCD policy may not cover what is an otherwise covered service, due to medical necessity requirements. An example of this would be “if you recommend a brace but it doesn’t meet the requirement for dispensing that particular DME for the diagnosis,” said Ms. Brinson.

She recommends that staff dispensing the DME be trained to understand what items are medically necessary under particular circumstances, as well as those that are not. “Physicians need to have this information too, so when they order the DME, they can make sure that medical necessity criteria have been met and documented.” Pay particular attention to orthopaedic DME, including ankle-foot/knee orthoses, canes and crutches, and spine orthoses.

Ms. Brinson also advises building the DME requirements into EHR templates. “If you are ordering DME while you are in the template for sprained ankle, for example, it’s faster if you’ve set up the requirements. Plus, the physician will know which documentation elements to include in the note” she said.

Finally, after the ABN is properly discussed and signed, do not forget to append the correct modifier on the claim form (Table 2). Keep in mind that if Medicare denies the item or service and there is no signed ABN on file indicating that the patient was informed, you cannot bill the patient and will have to delete the charge for the item or service.

The ABN process does not have to be complex or time consuming. Focus on items and services relevant to your practice, get
organized, and train physicians and staff (Table 3).

“Notifying Medicare patients that they might have some financial responsibility can feel like a touchy subject,” she acknowledged. “But patients appreciate when you have your story straight and present the facts in a way that allows them to make an informed decision.”

Cheryl Toth, MBA, is a business writer with KZA, which develops and delivers Current Procedural Terminology coding and practice management workshops presented by AAOS in conjunction with KZA.