Medicare implements new advanced beneficiary notice form

Q: I heard that there is a new advanced beneficiary notice (ABN) form for Medicare patients. When do I use it?

A: CMS announced that physicians could begin using a redesigned ABN form on May 3, 2008. Physicians are required to begin using the new form by Sept. 1, 2008. It is available from the CMS Web site.

The ABN is used when a physician provides a service to a Medicare beneficiary that the physician expects will not be covered under Medicare. The service that is being provided may sometimes be covered by Medicare, but not under specific circumstances, such as a Medicare coverage decision that prohibits payment for the service for a certain diagnosis code or when the service is being provided more often than allowed by Medicare. The important thing to remember is that the form is only required if the service is covered in some situations, but is unlikely to be covered in this one.

Q: What does the form do?

A: The form provides a record for the physician that the patient knew in advance of receiving a particular service that the service likely would not be covered by Medicare. In many cases, the patient may be responsible for paying for the service out-of-pocket. Filling out an ABN allows the physician to charge the patient any amount without the monetary limits imposed by Medicare.

Q: Do I have to submit the form to anyone?

A: No. The physician needs to keep a copy and provide a copy to the patient.

Q: Should I use this form for all of my patients, just to be safe?

A: No, this is prohibited by Medicare. If you expect that the service will be covered by Medicare, you may not use the form.

Q: So, do I use this form for Medicare patients every time I provide a service that is not going to be covered by Medicare?

A: Physicians are not required to use the ABN for services that are never covered by Medicare, such as travel vaccinations or cosmetic procedures. In the past, Medicare had suggested that physicians use a different form called the Notice of Exclusion from Medicare Benefits. That form could be used—but was not required—for services that never have been covered.

One of the significant changes made to the new ABN was to make the language more generic, eliminating the need for the Notice of Exclusion from Medicare Benefits form. The ABN can be used in both circumstances.

Q: What else has changed about the form?

A: In the past, there was also a separate form used for laboratory services. This also has been integrated into the ABN. The content of the lab form has not changed much. Most notably, the optional field for estimated cost is now a mandatory field.

CMS has also added a checkbox that would allow a patient to indicate that he does not want a claim submitted to Medicare for the service and that he gives up all appeal rights by doing so. Physicians should be careful about strongly recommending that a patient give up appeal rights and make sure that the patient understands what he or she is signing.

Q: What are the consequences of not using the form?

A: If a physician provides a service that he or she could have reasonably expected not to be covered in this specific circumstance, the patient may not be required to pay. Medicare may not pay a laboratory to which a physician refers a test if the physician failed to have the patient complete a form in advance and then Medicare declines to cover it.

Other billing questions

Q: Can I bill a Welcome to Medicare exam on the same date as a problem-based office visit?

A: Yes, as long as both services are performed and documented in the medical record. The Welcome to Medicare exam was first introduced as a benefit in 2005 and so far has had relatively low utilization. The exam is focused on history and screening. More information on this screening exam can be found online.

In order to be paid for both the Welcome to Medicare exam and the problem-based office visit, modifier 25 must be appended to the problem-based office visit code (e.g. 99213).

Q: I saw that there was a new code for a medical team conference. How do I use this code?

A: A new code for a medical team conference lasting longer than 30 minutes was added to Current Procedural Terminology in 2008. This new code (99367) allows physicians to report a service in which three or more qualified health care professionals of various specialties or disciplines meet to discuss an individual patient. The conference would not involve the patient. If the patient was present, other codes such as those pertaining to office visits would be used.

Q: Does anyone pay for this service?

A: Medicare considers the payment for this service to be bundled into its payment for evaluation and management services, meaning that physicians may not charge patients for it. Some private insurers may cover it, but the 30-minute time requirement for the service has dissuaded most internists from using it.