advance beneficiary notice - ahima

© Copyright 2009 American Health Information Management Association. All rights reserved.

Advance Beneficiary

Notice

Practical Tools for Seminar Learning

Disclaimer

AHIMA • http://campus.ahima.org

i

The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.

How to earn one (1) CEU for participation

To earn one (1) continuing education unit, each participant must do the following: Step 1: Listen to the seminar, via Webcast link or audio CD. Step 2: Complete the assessment quiz contained in this resource book.

Use the included answer key. Do not return the quiz to AHIMA. Save it for your records.

Step 3: EACH LISTENER must visit

http://campus.ahima.org/audio/fastfactsresources.html and complete the sign-in form and the seminar evaluation.

Step 4: After you complete the evaluation, you will receive your CE certificate which

you should print for your records. The certificate must be retained by each participant as a record of their participation, along with a copy of their completed quiz.

Faculty


ii

Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA

Shelley C. Safian, an Associate Professor for the Medical Billing and Insurance Coding program currently teaching in the online environment.

Safian is a Certified Coding Specialist-Physician-based from the American Health Information Management Association (AHIMA) and a Certified Professional Coder- Hospital and Certified Professional Coder – Instructor from the American Academy of Professional Coders (AAPC). She also holds a National Certified Insurance Coding Specialist (NCICS) designation, as well as that of Certified HIPAA Administrator (CHA).

Safian completed her Graduate Certificate in Health Care Management in June 2005 at Keller Graduate School of Management. The University of Phoenix awarded her Master of Arts/Organizational Management degree in 2002. Currently, she is working toward her PhD in Healthcare Administration.

The Florida Association of Post-secondary Schools and Colleges (FAPSC) named Safian Faculty Member of the Year 2006–2007. Herzing College, Winter Park honored Safian by naming her 2007 Teacher of the Year, and she was awarded the Faculty Scholarship Award—First Runner Up for the Herzing College System for 2006.

Safian sits on the AHIMA Classification Practice Council and is the Newsletter Chair for the Central Florida Health Information Management Association (CFHIMA).

McGraw-Hill Higher Education published Insurance Coding & Electronic Claims for the Medical Office by Safian in July, 2005. Her second, third, and fourth books, The Complete Procedure Coding Book, The Complete Diagnosis Coding Book, and You Code It! A Case Studies Workbook were published simultaneously in February, 2008. Safian’s fifth book, Essentials of Healthcare Compliance was released by Cengage/Delmar Publishing in January 2009.

Table of Contents


Disclaimer ..................................................................................................................... i How to earn one (1) CEU for participation ......................................................................... i Faculty ......................................................................................................................... ii Beneficiary Notices Initiative ........................................................................................ 1-3 Mandatory ABN Uses ...................................................................................................... 3 Voluntary ABN Uses ........................................................................................................ 4 ABN Issuers (Notifiers) ................................................................................................... 4 ABN Recipients .............................................................................................................. 5 ABN Triggering Events ................................................................................................. 5-6 CMS-R-131 G .............................................................................................................. 7-8 Bottom Line ................................................................................................................... 8 Resource/Reference List ................................................................................................. 9 AHIMA Audio Seminars/Webinars .................................................................................... 9 About assessment quiz .................................................................................................. 10 Thank you for attending (with link for evaluation survey) ................................................. 10 Appendix .................................................................................................................. 11 Web Resource List Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key

Advance Beneficiary Notice

AHIMA • http://campus.ahima.org 1

Notes/Comments

Beneficiary Notices Initiative

New Name (since March 3, 2008)

Advance Beneficiary Notice of Noncoverage

1


Revised ABN – Form CMS-R-131• CMS-R-131 G (General)• CMS-R-131 L (Laboratory)

ABN-G & ABN-L no longer valid

For all situations where Medicare payment is expected to be denied

2



Notes/Comments


Revised ABN may also be used for Voluntary Notification of Financial Liability

Eliminates most uses for the Notice of Exclusion from Medicare Benefits (NEMB)

3


Social Security Act, Section 1879

“Requires a provider to notify a beneficiary in advance when he or she believes that items or services will likely be denied either as not reasonable and necessary or as constituting custodial care”

Continued…

4



Notes/Comments


Social Security Act, Section 1879

“If such notice is not given, providers may not shift financial liability for such items or services to beneficial liability for such items or services to beneficiaries should a claim for such items or services be denied by Medicare.”

5

Mandatory ABN Uses

Not reasonable and necessaryMedical equipment and/or supplies denied in advanceCustodial careHospice patient not terminally illUnsolicited telephone contacts

6



Notes/Comments

Voluntary ABN Uses

Care that is statutorily excluded from coverage under MedicareFails to meet a technical benefit requirementIn place of NEMB for care that was never covered

7

ABN Issuers (Notifiers)

PhysiciansPractitionersProviders such as laboratoriesSuppliersMedicare contractorsUtilization review committees

8



Notes/Comments

ABN Recipients

Beneficiaries under• Medicare FFS• Medicare Advantage• Skilled Nursing Facilities (SNFs) must

use the revised ABN for denied applicable to Medicare Part B only

9

ABN Triggering Events

Whenever limitation on liability applies

InitiationsReductionsTerminations

10



Notes/Comments


InitiationsBeginning of new patient encounterStart of plan of careBeginning of treatment

11


ReductionsDecrease in a component of care

TerminationsDiscontinuation of services or items

12



Notes/Comments

CMS-R-131 G

13

CMS-R-131 G

14



Notes/Comments

CMS-R-131 G

15

Bottom Line

Clear directives when you MUST use an ABNUse this, or a version, for ALL patients in cases where co-insurance or high deductibles are in effect to avoid collection hassles.

16



Notes/Comments

Resource/Reference List

CMS website: Beneficiary Notice Initiativewww.cms.hhs.gov/BNI

Medicare Claims Processing Manual Publication 100-04, Chapter 50, Section 50

17

AHIMA Audio Seminars/Webinars

Visit our Web site http://campus.AHIMA.orgfor updated information on the current seminar schedule. While online, you can also register for live seminars or order CDs and Webcasts of past seminars.

© 2009 American Health Information Management Association



Notes/Comments

Assessment

To access the assessment quiz that follows this seminar, download the seminar’s resource book at

http://campus.ahima.org/audio/fastfactsresources.html

Thank you!

Please visit the AHIMA Audio Seminars Web site to sign-in and complete your evaluation form to receive your CEU certificate at:

http://campus.ahima.org/audio/fastfactsresources.html

Appendix


Web Resource List Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key

Appendix


Web Resource List CMS website: Beneficiary Notice Initiative www.cms.hhs.gov/BNI

Medicare Claims Processing Manual Publication 100-04, Chapter 50, Section 50

Assessment Quiz – Advance Beneficiary Notice

AHIMA • http://campus.ahima.org ANSWERS to this quiz are found on the last page of the seminar resource book, Practical Tools for Seminar Learning.

To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a copy of the completed quiz with your CE certificate. Do not send a copy to AHIMA.

1. The new ABN must be used as of:

a. March 3, 2008 b. March 1, 2009 c. January 1, 2009 d. July 1, 2009

2. The new ABN is CMS form __________.

a. CMS-ABN- G b. ABN-CMS-131 c. CMS-G-131 d. CMS-R-131

3. True or false? The new ABN includes an optional

“cost estimate” field. a. True b. False

4. The new ABN is designed to be used instead of

a. VNFL b. CMS7 c. NEMB d. ABN-R

5. True or false? If an ABN should have been

issued, is not issued, and the claim is denied, the notifier can bill the beneficiary to be paid for the procedure or item. a. True b. False

6. When a procedure is considered “not reasonable

and necessary” by Medicare, an ABN is a. Mandatory b. Voluntary c. Unnecessary d. Only required for Part A beneficiaries

7. When a physician writes an order for an x-ray,

and the imaging center provides the technical aspect of this service, a. the physician and the imaging center must

issue separate ABNs. b. the physician and the imaging center may

issue a joint ABN. c. only the physician should issue the ABN. d. only the imaging center should issue the ABN.

8. All of the following are considered ABN triggering

events except: a. Initiation b. Reduction c. Conversion d. Termination

9. True or false? When filling in the estimated cost

for a procedure on an ABN, the amount may be stated as a range, such as $100 – $150. a. True b. False

10. True or false? CMS recommends that all ABNs be

issued with Option 2 pre-checked off to make it easier for the beneficiary. a. True b. False

Do not send a copy of completed quizzes to AHIMA. Please keep them with your CE certificate, for your records. Be sure to sign-in and complete your evaluation form, to receive your certificate, at

http://campus.ahima.org/audio/fastfactsresources.html.

To receive your

CE Certificate

visit http://campus.ahima.org/audio/fastfactsresources.html

click on the link to

“Sign In and Complete Online Evaluation” listed for this seminar.

You will be automatically linked to the

CE certificate for this seminar after completing the evaluation.

Each participant expecting to receive continuing education credit must complete the online evaluation and sign-in information,

in order to view and print the CE certificate.


Quiz Answer Key Fast Facts Audio Seminar: Advance Beneficiary Notice 1: b; 2: d; 3: false; 4: c; 5: false; 6: a; 7: b; 8: c; 9: true; 10: false Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA. Please keep it with your CE certificate, for your records.

advance beneficiary notice - ahima

Documents