The ABN should be provided to a Medicare patient prior to rendering a service that Medicare might otherwise cover, however is likely to be denied on this particular occasion. For example, when you have good reason to expect the procedure will be denied based on other Medicare denials and local medical review policies, or that the patient's diagnosis or procedure does not meet the Medicare program standards for medical necessity.

The ABN is intended to provide the patient advanced notice that it is likely the procedure will be denied and allows the patient to make an informed decision whether to receive the service for which he or she may be personally responsible. Claims for such services may be submitted with either the HCPCS modifier "GA" ("waiver of liability statement issued as required by payer policy") or "GX" ("notice of liability issued, voluntary under payer policy"). If the service is denied and a signed ABN is not on file, the physician may not hold the patient responsible for payment.

There may be instances in which the service to be rendered is expected to be denied however a signed ABN was not obtained because the patient refused to sign it. If this is the case, the physician may choose not to render the service, unless the health and safety of the patient is at risk. Another scenario might be that the patient presents a medical emergency and under great duress in which EMTALA (Emergency Medical Treatment and Labor Act) provisions apply and therefore could not have been provided with an ABN prior to rendering treatment. In these situations, the claim may be submitted to Medicare, however the modifier "GZ" should be included on the claim form to indicate "item or service expected to be denied as not reasonable and necessary." Although in these situations Medicare will most likely hold the provider financially liable.

Remember it is unlawful to provide the ABN on a routine indiscriminate basis. The ABN is not intended to be a blanket statement to protect a physician from financial liability. Generic ABNs simply stating "Medicare will likely deny this service" are also unacceptable. The ABN should be provided when there is a specific reason to believe the service will be denied and the specific reason should be indicated.

Recent Centers for Medicare and Medicaid Services (CMS) changes to the ABN process included revision to the ABN form itself making the Notice of Exclusions from Medicare Benefits (NEMB) form essentially obsolete. A revised version of the Advance Beneficiary Notice (ABN) form became available March 3, 2008 and fully implemented September 1, 2008. The revised form has a new name: "Advance Beneficiary Notice of Noncoverage" however is still referred to as the "ABN". The cost-estimate field is new to the final form and critical to remaining in compliance. It is therefore mandatory to complete this field. The form should continue to be provided to Medicare beneficiaries before rendering a service that is likely to be denied by Medicare.

• It is a consolidated version of the two existing ABN forms, the ABN-G for general services and the ABN-L for lab services, so it replaces both;

• it may replace the use of the Notice of Exclusion from Medicare Benefits form (NEMB);

• provides a field to indicate the cost estimate of the service(s) being performed (mandatory); and

• it includes a new option for beneficiaries that allows them to choose a service for which they will pay out-of-pocket, without having a claim submitted to Medicare

The revised form and instructions are available on the Beneficiary Notices page of the CMS Web site.

Medicare does not require claims to be submitted for non-covered services, such as dental care, cosmetic surgery, preventative medicine, and routine physical examinations. However, if the patient believes that a service may be covered, requests that a claim be submitted, or wishes to receive a formal Medicare determination for consideration by a supplemental insurance, a claim for the non-covered service must be submitted.

When submitting a claim for non-covered services, you may wish to apply the HCPCS modifier "GY" to the procedure code to indicate an item or service that is statutorily excluded or does not meet the definition of any Medicare benefit. Even though Medicare will "auto-deny" any procedure with the "GY" modifier, applying the modifier may speed the claims process and allow the patient to submit a claim to another carrier sooner. The "GY" may appear in addition to the "GX" when appropriate.

An ABN is not required when submitting claims for non-covered services, but rather is voluntary in these situations. Many providers prefer providing Medicare patients written notice that the service to be rendered is excluded from Medicare benefits. Doing so assures them that the patient has acknowledged that they will be responsible for payment. The ABN in these situations allows the patient to make an informed decision about whether or not they want to receive the service or treatment knowing that they will be personally financially responsible, and also allows them to be more active in their own health care treatment decisions.

Before electing to not obtain a signed ABN or submit a claim, it is imperative that you be certain that the service is statutorily excluded. If you charge a patient your standard fee for services that may possibly be covered, you may be charged with violating Medicare policy, and risk penalties or exclusion from Medicare and other federal health programs.

For more information or to download a copy of the ABN you may visit the Beneficiary Notices Section of the CMS Web site.

Local Coverage Decisions (LCD)

For those who find it difficult to determine whether a procedure is a covered Medicare benefit, Medicare has made it easier by posting national and local coverage policies on the CMS Web site. The Medicare Coverage Database allows a search for local and national policy by CPT code or by keyword.

Moreover, according to CMS Program Memorandum dated January 3, 2003, as of April 1, 2003, providers may notice a new remittance advice remark code "N115" accompanying procedures that were denied due to a local coverage decision. This will ease the tensions with determining when to provide an ABN.

N115 - "This decision was based on a local coverage decision (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.hhs.gov/mcd/search.asp."

Now that LCDs are easily accessible it is important to review your Medicare carrier's policies as interpretations of Medicare policy may vary from state to state. For example, some carriers will reimburse for the removal of tori, while others consider it an excluded service.

This new rule may affect OMSs, especially those enrolled prior to 2003 when Medicare began using the PECOS database, as well as general dentists that order and/or refer but have never enrolled in the Medicare program. To continue to order or refer for Medicare beneficiaries a provider, including OMSs, must be registered in PECOS. The AAOMS encourages all members to verify their enrollment information in the Internet-based PECOS system, regardless as to when enrolled in Medicare. A recent CMS memorandum provides specific instructions for re-enrolling providers initially enrolled more than six years ago. It also makes clear that any dentist that orders or refers items or services must be enrolled. If a required referring or ordering physician/health care practitioner listed on a claim is not in PECOS (or in some cases, the Medicare carrier's "master provider file"), the claim of the provider that actually carries out the referred or ordered item or service will not be paid.

A recent CMS Transmittal and MLN Matters article further explain what this means for providers.

Some important points to note:

• The new policy only applies to physicians billing the Medicare fee-for-service program. It does not apply to Medicare Advantage or non-Medicare insurers.

• In the inpatient hospital setting and nursing facility setting, any physicians and qualified NPPs who perform an initial evaluation may bill an initial hospital care visit code (CPT code 99221 - 99223) or nursing facility care visit code (CPT 99304 - 99306), where appropriate. This means more than one provider can report a code in the 99221 - 99223 range on the same day for the same patient. The principal physician of record will append modifier "-AI" Principal Physician of Record, to the E/M code when billed. This modifier will identify the physician who oversees the patient's care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient will bill only the E/M code for the complexity level performed. However, claims that include the "-AI" modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.

• Emergency department visits (codes 99281 - 99288) - physician billing for emergency department services provided to patient by both patient's personal physician and emergency department (ED) physician. If the ED physician, based on the advice of the patient's personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service. The patient's personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department. If the patient's personal physician does not come to the hospital to see the patient, but only advises the ED physician by telephone, then the patient's personal physician may not bill.

For additional information be sure to read the CMS Transmittal and MLN Matters article. AAOMS will continue to monitor this issue to keep you informed.

HCPCS modifier -GA has been revised to mean "waiver of liability statement issued as required by payer policy" and a new modifier, -GX, has been created to describe "notice of liability issued, voluntary under payer policy". An example of when the -GX modifier would be appended to a code on the claim form would be routine dentoalveolar surgery. Keep in mind, the claim technically would not have to be submitted if the service is one that is statutorily excluded from Medicare, such as extractions not prior to radiation treatment. If, however, a patient insisted the claim be filed, the -GY modifier (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would appear in addition to the -GX modifier. Medicare will automatically assign beneficiary liability to any claim where the -GA or -GX is present. The new modifiers must be used effective April 1, 2010.

An example of the phishing email can be found through this link: http://www.cdc.gov/hoaxes_rumors.html

Users that click on the embedded link in the email are at risk of having malicious code installed on their system. CDC reminds users to take the following steps to reduce the risk of being a victim of a phishing attack:

• Do not open or respond to unsolicited email messages
• Do not click links embedded in emails from unknown senders
• Use caution when entering personal information online
• Update anti-virus, spyware, firewall, and anti-spam software regularly

CMS has made mostly minor edits to the forms, such as using "Final Adverse Actions" instead of "Adverse Legal Actions," throughout the form. Section 17 of the new CMS-855I does not ask you to check off documents that you are attaching such as a medical license, DEA or medical school certificate, however, your contractor will use the Internet to verify information in an effort to minimize the amount of supporting documentation you are required to send. They will search state and school databases to verify that information is correct. Your carrier may request copies of a degree or certificate when information can't be verified online.

If you've recently used and sent an old application carriers are instructed to accept older versions of the forms with "02/08" in the bottom-left corner until Nov. 30. You can continue using the 855B and 855I forms marked with 02/08 up until Nov. 30 - but those forms must be in your carrier's hands by Nov. 30.

Other changes to the 855I include:

• removing the reference to the Healthcare Integrity and Protection Data Bank from pg. 12
• clarifying a "individual (type 1) NPI" should be provided on pg. 4;
• revising and clarifying #2 on the Certification Statement on pg. 25; and
• adding the phrase "(blue preferred)" after "All signatures must be original and signed in ink" on pg. 26.

Specific changes to CMS-855B are:

• removed "Slide Preparation Facility" from pages 1 and 9
• removed "Public Health/Welfare Agency" from pg. 9;
• removed the sentence "If you are a single specialty clinic/group practice, the specialty must be reported" from page 9; and
• removed the reference to the Healthcare Integrity and Protection Data Bank from pg. 11.

To obtain more information you can visit the CMS website.