MD - Health Care Compliance Association

More documents

Recommendations

Info

Improving revenue through compliance ...continued from page 11 In addition, the ABN Reference Guide was revised with added services examples given and estimated costs listed. Some of these were prompted by reviewing the services billed for Medicare patients such as the PPD (purified protein derivative skin test for tuberculosis screening). Many Medicare patents at a particular office were being seen for pre-admission physicals for assisted living admissions. Since the PPD is being performed as a screening test and not due to exposure, it is not expected to be covered. This and any EKGs or other admission tests made mandatory by the assisted living facility are not always deemed as “medically necessary” by Medicare. Without an ABN being obtained, the bills for these services would all have to be written off. Another common error was that neither option had been checked off by the patient (option 1 “yes, I want the service”, or option 2 “no, I don’t want the service”). The staff was instructed to remind patients or to check off option 1 in the patient’s presence if they neglected to do so when they were signing and dating the form. The document is not valid without an option checked or without a date and signature. Bundled services ABNs should not be used for “bundled services.” Bundled services are certain services that Medicare considers to be included in the visit or procedure provided. Examples of bundled services are: ■ Dip urinalysis (81002 etc.) ■ Pulse oximetry (94760) ■ Peak flow ■ Conscious sedation (99141) ■ Some prolonged services codes (99358- 99359) Connecting the dots The ABN should be attached to the chart or encounter form (superbill) of any Medicare patient being seen. This should be done at registration. Even a sick patient often ends up with potentially non-covered services being performed “while they are there.” A sick visit is often the opportunity used by either patient or provider to receive additional services, like screening tests or immunizations. The medical assistant or nurse should have the form ready for when the patient is in the exam room and before any questionable services are performed. It is imperative that the services and reason (BECAUSE section) be completed prior to the patient receiving the services since it is up to the patient as to whether or not they want any potentially non-covered services. This is a CMS requirement as well. Providers can add to or append the items on the form as they see fit in the course of their encounter with the patient. Use of a reference guide can aid in choosing which services may apply and can also aid in supplying the estimated cost on the form. Now that you have a completed and signed ABN, what do you do The clinical staff needs to make sure that the form makes it along with the encounter form/superbill to the check out person or data entry clerk. Here they can determine what is statutorily non-covered (-GY modifier needs to be added) or what needs to be billed with the - GA modifier (items listed in the SERVICES section of the ABN). The CPT or HCPCS code(s) and ICD-9 code(s) should be linked appropriately, modifiers appended as indicated, and monies collected for any statutorily non-covered services at this point. When under a CAP agreement with Medicare The new Competitive Acquisition Program (CAP) was scheduled to open for enrollment in the fall of 2005. However, a combination of vendor non-interest and national disasters has now pushed back the process until tentatively summer 2006. If and when this goes into effect, providers who have signed up for the program may be responsible for getting ABNs signed for a third party i.e., a pharmaceutical distributor. Therefore, it is important to learn how to successfully execute a proper ABN so that providers will be prepared to take on this function for a third party in the future. Unless the structure of the proposed CAP agreement changes significantly, be ready to gear up. Conclusions A properly executed ABN will: ■ Allow you to balance-bill the patient ■ Help recoup otherwise lost revenue ■ Reduce write-offs ■ Improve cash collection, cash flow, and revenue Although the use of ABNs may seem to be a burdensome task, the end result will be a boost to your bottom line. Education, training, and coordination of staff can make for an organized effort that will reap positive benefits. ■ Contact Us! http://www.hcca-info.org info@hcca-info.org Fax: (952) 988-0146 HCCA 5780 Lincoln Drive, Suite 120 Minneapolis, MN 55436 Phone: 888-580-8373 To learn how to place an advertisment in Compliance Today, contact Margaret Dragon: e-mail: margaret.dragon@hcca-info.org phone: 781-593-4924 January 2006 12 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Figure 1: ABN Reference Guide Services that may require an ABN (use the –GA modifier) ■ Medically unnecessary services (clue may be dx is a V-code, but not all V-codes) ■ Most screening tests/services (even covered screenings have frequency requirements) ■ Baseline EKG (93000 $28 or 93005, $19) ■ EKG as part of a routine physical (93000 $28 or 93005, $19) ■ Digital Rectal Exam (DRE) for prostate screening (G0102, usually done as part of a routine PE) more often than Q12mo., $23 ■ Pap smear (Q0091, $42) more often than Q2yrs. ■ Visit for well woman exam (E/M code eg G0101, $39) more often than Q2yrs. ■ Removal of skin tags or other benign lesions for cosmetic reasons 11200 $73, 11201, $18 ■ Screening flexible sigmoidoscopy (G0104, $131 and G0106, $147) more often than Q5yr. ■ PPD for TB screening 86580, $18 ■ B12 injections (frequency & medical necessity are issues) J3420, $5 ■ Contraception injectables i.e. DepoProvera J1055 ■ Most vaccines w/o medical necessity (e.g. prophylactic tetanus or Td) ■ Vaccines beyond the frequency guidelines (e.g. peumonia vaccine is a once in a lifetime benefit). NOTE: most vaccines are not covered and should be billed with the –GY modifier (no ABN needed). ■ Welcome to Medicare Visit (G0034, $101)—within 6 months of eligibility ■ EKG with the Welcome to Medicare Visit (G0366, $28)—within 6 months of eligibility Services that do NOT require an ABN or a modifier: ■ Sick visits Services that do NOT require an ABN but need a –GY modifier: ■ Preventive Care Visits i.e. routine or annual physical/PE (99387 or 99397) ■ Most screening tests/services if “statutorily non-covered” ■ Vaccines for travel or non-covered vaccines (e.g. Hepatitis A) ■ Administration of travel/non-covered vaccines (90471 or 90472) Cosmetic surgery ■ Pre-Op exam for cosmetic surgery plus any tests performed as pre-op ■ Services provided to immediate relatives (any & all services if patient is related to M.D., D.O. or mid-level) NOTE: This list is for reference only and is not all-inclusive. Fees used are for example only and are based on Medicare rates in the mid-Atlantic, 2005. Health Care Compliance Association • 888-580-8373 • www.hcca-info.org 13 January 2006
Page 1 and 2: Volume Eight Number One January 200
Page 3 and 4: ASK ON THE LEADERSHIP ONCALENDAR JO
Page 5 and 6: Join us for the following HCCA Audi
Page 7 and 8: in 2006 will assess hospital compli
Page 9 and 10: By Susan C. L. Theuns Editor’s no
Page 11: ■ ABNs were used for preventive c
Page 15 and 16: feature article Editor’s note: Th
Page 17 and 18: GJ: Yes. The Fraud, Waste, and Abus
Page 20: ■ There will be Compliance expert
Page 23 and 24: Here’s your chance to share your
Page 25: espective nonprofit law compliance
Page 29 and 30: suffix that identifies package size
Page 31 and 32: By José A. Tabuena JOSÉ A. TABUEN
Page 33 and 34: AP: As far as the Auditing and Moni
Page 35 and 36: that would provide the intelligence
Page 37 and 38: Case study of Dana Farber Cancer In
Page 39 and 40: JOSEPH M. WATT ■ Solicit staff an
Page 41 and 42: including the three objectives set
Page 43: expect a measurable impact of compl
Page 46 and 47: New HCCA Members ...continued from
Page 48: C ORPORATE C OMPLIANCE & ETHICS: G

MD - Health Care Compliance Association

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?