Sunday, February 6, 2011

When we should ask ABN from patient in ambulance billing - non emergency transport

ABN Requirements for Non-Emergency Transports

The ABN is a written notice a physician or supplier gives to a Medicare beneficiary before items or services are furnished when the physician or supplier believes that Medicare probably or certainly will not pay for some or all of the items or services on the basis of certain Medicare statutory exclusions.
An ABN is rarely used for ambulance services, and may only be issued for non-emergency transports. An ABN may not be used when a beneficiary is under great duress. A beneficiary is considered to be under great duress when his or her medical condition requires emergency care.

An ABN may be needed and may be used for non-emergency transports in the following situations:

a) A transport by air ambulance when the transporting entity has a reasonable basis to believe that the transport can be done safely and effectively by ground ambulance transportation.
b) A level of care downgrade, e.g., from ALS-2 to ALS-1, or from ALS to Basic Life Support (BLS), when the transport at the lower level of care is a covered transport.
c) A transport from a residence to a hospital for a service that can be performed more economically in the beneficiary’s home, and
d) A transport of a skilled nursing facility patient to a hospital or to another SNF for a service that can be performed more economically in the first SNF.
An ABN is not needed, and should not be used in the following situations:
a) Any denial where the patient could be transported safely by other means.
b) Any denial that is based on not meeting an origin or destination requirement.
c) A denial for mileage that is beyond the nearest appropriate facility.
d) A denial where the PCS or accepted alternative (i.e. certified mail) is not obtained.
e) A convenience discharge, e.g., where the patient is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family.

The Notice of Exclusions from Medicare Benefits (NEMB) is an optional form that CMS developed to assist suppliers in informing beneficiaries that the services they are receiving are excluded from Medicare benefits. When an ABN is not appropriate to use because medical necessity is not the basis for the expected denial, an NEMB may be used. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services.

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