TOPIC

TOPIC: Determine medical necessity and know when to obtain an ABN

Determining if a service is medically necessary
Facilities must be able to screen for the medical necessity of a service before rendering it to Medicare patients. Staff registering patients must have access to national coverage determinations (NCD) and local medical review policies (LMRP). A computerized method may be the best solution. Many vendors have automated this process.

Use the following three-step process to determine the medical necessity of services:

Verify whether the test or service has an LMRP or NCD.
Proceed and perform the test or service ordered if the test or service does not have limited coverage under an NCD or LMRP, .
Review the signs, symptoms, or diagnoses provided by the physician and determine whether the test is considered medically necessary based on the physician’s documentation, if the test or service does have limited coverage under and NCD or LMRP

ABN decision tree
Whether an advance beneficiary notice (ABN) should be given depends on the physician’s or supplier’s expectation of Medicare payment or denial. Use these guidelines for determining when to obtain an ABN.

Do not obtain an ABN

if the physician or supplier expects Medicare to pay (e.g., if the test or service to be provided meets medical necessity requirements of NCDs or LMRPs)
if the physician or supplier claims to never know whether Medicare will pay for a test or service
if the item or service is not a Medicare benefit (e.g., routine physical, tests in the absence of signs and symptoms, routine foot care, dental care)
if Medicare is expected to deny payment for an item or service that is a Medicare benefit because it does not meet a technical benefit requirement (e.g., diabetic care shoes not prescribed by a podiatrist or other qualified physician)

Do obtain an ABN

if you expect Medicare to deny payment (entirely or in part) for the item or service because it is not reasonable and necessary based on an NCD or LMRP (this applies to all assigned Part B items and services and to unassigned physicians’ services and medical equipment and supplies)
if certain screening tests (e.g., mammography, pap smear, pelvic exam, glaucoma, prostate cancer, colorectal cancer) work within frequency limits; obtain an ABN when you expect Medicare to deny payment for frequency of the test
if you expect Medicare to deny payment for medical equipment and supplies because it violates the prohibition on unsolicited telephone contracts or supplier number requirements

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