When providing Durable Medical Equipment (DME) to Medicare Part B beneficiaries, there are certain situations where an Advanced Beneficiary Notice (ABN) may be required.  An ABN should be issued to a patient prior to providing DME that is usually covered by Medicare, but is not covered in this particular instance.  In this situation, the ABN should be issued to the patient prior to delivery or dispensing, allowing the patient enough time to decide that they wish to accept financial responsibility.

Example

Coverage for the EXTREMIT-EASE® Compression Garment by AMERX Health Care falls under the DMEMAC Surgical Dressing policy which states a qualifying wound is required for coverage of the garment.  In many cases, patients enjoy so much success with their EXTREMIT-EASE that they want to continue using it to address venous leg disease even after their wound has healed.  However, the second compression garment is not covered by the DMEMACs in the absence of a qualifying wound.  The patient can self-pay for the garment in these situations and this is an example of when an ABN should be issued to the patient.

Your ABN Form May Be Expired!

ABN forms are available from CMS and they have expiration dates.  CMS has issued a new ABN form that is effective now.  The last ABN form that was issued had an expiration date of 6/30/23.  Check the bottom right corner of the form you are using to ensure it is not expired!  The current forms can be downloaded from the CMS Fee-For-Service ABN page by clicking on “ABN Forms English and Spanish.”  This new form expires on 1/31/26.

References

  1. CPT 2023 Professional Edition Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2022 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
  2. National Correct Coding Initiative Policy Manual For Medicare Services  https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
  3. Chapter I, General Correct Coding Policies For National Correct Coding Initiative Policy Manual For Medicare Services
  4. Medicare Claims Processing Manual, Chapter 30, Section 50 – Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf

DISCLAIMER: The information provided here is intended to educate healthcare providers regarding compliance with ICD, CPT, and HCPCS coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date.  The existence of a code does not guarantee payment.

Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
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Dr. Lehrman is a podiatrist practicing in Fort Collins, CO and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation. Dr. Lehrman is a Certified Professional Coder and Certified Professional Medical Auditor. He serves as a staff liaison at the AMA CPT® Editorial Panel meetings where CPT codes are created, edited, and deleted. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. Dr Lehrman is a Fellow of the American Academy of Podiatric Practice Management, Past Director of the American Professional Wound Care Association Board of Directors, and is a Past Chairman of the Board of the American Society of Podiatric Surgeons. Dr. Lehrman is also on the editorial advisory board of the journal WOUNDS.