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Who has the responsibility to inform patients about the possibility that the test or surgical procedure they are to undergo may or may not be covered by Medicare? Quite often, it is the ophthalmic assistant or technician.
The new and improved Advance Beneficiary Notice (ABN) — renamed the Advance Beneficiary Notice of Noncoverage — became effective March 1. This Medicare form replaces the former ABN-G and the Notice of Exclusion of Medicare Benefits.
The ABN should be used whenever there is uncertainty as to whether payment will be received for services rendered to Medicare beneficiaries that are considered to be limited, based on the:
a) Diagnosis, and/or
b) Frequency of the service performed
For example, the physician may order external ocular photography for a diagnosis that may or may not be covered for that particular Medicare plan. Typical covered diagnosis codes for 92285 include:
- 373.4 Infective dermatitis of eyelid of types resulting in deformity — first code underlying disease as: leprosy (030.0...030.9), lupus vulgaris (tuberculous) (017.0), yaws (102.0...102.9)
- 373.5 Other infective dermatitis of eyelid — first code underlying disease as: actinomycosis (039.3), impetigo (684), mycotic dermatitis (110.0...111.9), vaccinia (051.0), postvaccination (999.0)
- 373.6 Parasitic infestation of eyelid — first code underlying disease as: leishmaniasis (085.0-085.9), loiasis (125.2), onchocerciasis (125.3), pediculosis (132.0)
- 374.00 Entropion, unspecified
- 374.01 Senile entropion
- 374.02 Mechanical entropion
- 374.03 Spastic entropion
- 374.04 Cicatricial entropion
- 374.05 Trichiasis without entropion
- 374.10 Ectropion, unspecified
- 374.11 Senile ectropion
- 374.12 Mechanical ectropion
- 374.13 Spastic ectropion
- 374.14 Cicatricial ectropion
- 374.30 Ptosis of eyelid, unspecified
- 374.31 Paralytic ptosis
- 374.32 Myogenic ptosis
- 374.33 Mechanical ptosis
- 374.34 Blepharochalasis (pseudoptosis)
- 374.51 Xanthelasma of eyelid — first code underlying condition (272.0-272.9)
- 374.87 Dermatochalasis
- 375.15 Tear film insufficiency, unspecified (dry eye syndrome)
- 743.61 Congenital ptosis
- 743.62 Congenital deformities of eyelids (ablepharon, accessory eyelid, entropion)
- V52.2 Fitting and adjustment of prosthetic device and implant; includes removal of device, artificial eye
If the diagnosis is not covered, the patient has three options:
- Option 1: The patient wants the service and also wants Medicare billed for an official decision on payment, which is sent to the patient on a Medicare Summary Notice. The patient understands that if Medicare doesn’t pay, he or she is responsible for payment, but can appeal to Medicare. If Medicare does pay, the physician’s office will refund any payments the patient made to the office, less co-pays or deductibles.
- Option 2: The patient wants the service, but does not want Medicare to be billed. As the patient is responsible for payment, he or she cannot appeal if Medicare is not billed.
- Option 3: The patient does not want the service.
ABN Signature Challenges
By stating the following: “Medicare does not pay for everything, even some care that health care providers recommend,” you will reinforce the intent of the ABN before the patient begins to read the form.
After counseling the patient about the options available, he or she will either elect to have the service or decline. If the patient declines, you should inform the physician. If the patient chooses to have the service, he or she will select option one or two from above. You will need to inform the front office staff of the patient’s decision so that they can either collect payment from the patient or bill Medicare for the services rendered.
Remember – you are helping the patient to make an informed choice about treatment options and the corresponding financial responsibility. Always provide patients with an opportunity to ask questions.
- The ABN is for Medicare patients only.
- It is to be used when Medicare may or may not cover a procedure.
- Use of the ABN is recommended for:
- All oculoplastics procedures.
- Off-label applications of Avastin or Lucentis (primary approval for exudative macular degeneration 362.52: check local carrier determination (LCD)).
- When performing a test for which your LCD does not cover the diagnosis.
- When performing a special testing service at a greater frequency than “typical.”
- The ABN is necessary prior to surgery using presbyopic or astigmatic correcting IOLs.
- When using the ABN, you MUST append modifier –GA, which tells Medicare you have an ABN on file. Without it, if the claim is denied, the EOMB to the patient will state, “You should have been told that Medicare may not pay for this service. Therefore you are not responsible for payment.”
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About the author: Kim M. Ross, OCS, CPC, is the Academy’s coding specialist.