Step 1 – Tools

  • DME MAC Local Coverage Determinations (LCD’s)
  • NHIA Medicare for Denial Tools
  • Flow Charts
  • Cheat Sheets
  • Training and Education

Step 2 – Intake

  • Initial Referral
    • Use tools to determine if patient meets Medicare qualifications or needs billed for technical denial.
    • Does Secondary payer require a technical denial from Medicare for statutorily non-covered items

Step 3 – ABN

Advanced Beneficiary Notice

  • Purpose
    • To inform a Medicare beneficiary, before he or she receives specified items or services that otherwise might be paid for, that Medicare certainly or probably will not pay for them on that particular occasion.
    • Allow the beneficiary to make an informed decision on whether or not to receive the items or services for which he or she may need to pay for.

ABN Delivery Requirements

  • CMS 50.7.1
    • Delivered by a suitable notifier to a capable recipient and comprehended by the recipient.
    • Using the correct form.
      • CMS-R-296
    • Provided in advance of delivery
    • Explained in its entirety.
    • Completed and signed by the beneficiary or his/her representative.

In Advance of……

  • Far enough in advance of delivery that beneficiary does not feel pressured to sign.
    • In person notice
    • Telephone notice
      1. Content of conversation must be verifiable and not disputed by the beneficiary.
      2. Must be followed up immediately with a mailed notice or personal visit
        • If both a & b are met, the Medicare contractor will accept the time of the telephone notice as the time of ABN delivery.

No ABN Needed

  • If patient is receiving a statutorily non-covered item or a categorical exclusion, you do not need an ABN.
    • Examples of statutorily non-covered items:
      • Any therapy not administered via a DME pump (ABX, HYD, PM, etc.).  IV drip only.
      • Payment for items that do not meet the definition of durable medical equipment.
      • Payment for drugs and biologicals which are usually self-administered by the patient.
      • Patient does not meet Test of Permanence for TPN therapy
      • Enteral patient does is drinking formula.

ABN Must’s

  • Original documents and copies must be:
    • Readable
      • No “fancy” fonts – stick with Arial, Courier, etc.
        • If handwritten, must be legible to all parties involved.
        • Use at least 12 point font size
      • Do not highlight text
      • Written in lay language
      • Contents must be comprehended by the beneficiary or authorized representative.
      • Ensure that the entity notifying the patient of Medicare’s probably of denial is on the form header.

Authorized Representative

  • CMS 40.3.5
    • Person acting on the beneficiary’s behalf and best interest, and who does not have a conflict of interest with the beneficiary, when the beneficiary is unable to act for him/herself.
      • The spouse, unless legally separated.
      • An adult child
      • A parent
      • An adult sibling
      • A close friend (defined as “an adult who has exhibited special care and concern for the patient, who is familiar with the patient’s personal values, and who is reasonably available”).

Step 4 – Billing

  • A9270 – Non covered item or service
    • CMS states they do not allow the use of A9270 for denial of non Medicare-certified HHA nursing visits for patients.
    • Providers must use approved codes in place of A9270 when possible.
    • Examples:
      • J7799     NOC drugs, other than inhalation, administered through DME Include name of drug
      • J3490     Unclassified Drugs Include name of drug
      • J3590     Unclassified Biologics Include name of drug
      • A4223    Infusion supplies, not used with external infusion pump, cassette or bag

Billing Modifiers

  • GA – Waiver of Liability Issued
    • Indicates than a valid ABN is on file and allows provider to bill patient if not covered by Medicare.
  • GX – Notice of Liability Issued, Voluntary
    • Indicates that a voluntary ABN was issued for non covered services
    • Medicare will reject claims with GX modifier applied to covered charges
    • Can be combined with other modifiers
  • GY – Notice of Liability Not Required
    • Indicates patient received a non covered service
  • GZ
    • Indicates item or service expected to be denied as not reasonable and necessary.  When an ABN may be required but was not obtained.  Medicare will deny with a CO-204

Billing Tips

  • Be cautious of coding – S codes are not accepted by the DME MAC.
  • Set up claims based on your secondary payer allowables.
  • Ensure that your modifiers and narratives are attached to your claim.
  • DIF’s are required when patient is receiving a Medicare covered therapy and they do not meet the LCD criteria.
  • Have a Medicare for Denial payer set up in your sytem.
  • Have cash/denial posters flip claims to 2nd

Step 5 – Collections

  • Should have denials within 14 – 21 days of submission.
  • Timely filing limits apply