Blood Pressure Checks

The Centers for Medicare & Medicaid Services (CMS) has provided notification that Medicare Coverage Issues Manual, Section 50-42, Ambulatory Blood Pressure Monitoring, has been revised. This revision specifies that a physician is required to perform the interpretation of the data obtained through ambulatory blood pressure monitoring, but that there are no requirements regarding the setting in which the interpretation is performed. Everything else in this National Coverage Determination (NCD) remains unchanged. CMS transmittals are available in their entirety on the CMS Web site.

Instructions for Issuing an Advance Beneficiary Notice (ABN)

The Centers for Medicare & Medicaid Services (CMS) Program Memorandum AB-02-114 (CR 2219), dated July 31, 2002, provides specific instructions related to the use of Advance Beneficiary Notice (ABN) forms CMS-R-131-G and CMS-R-131-L. The CMS-R-131 G may be used for all situations, including laboratory tests. The CMS-R-131-L may be used for physician-ordered laboratory tests.

On the CMS-R-131-G form, providers are permitted to customize the header, the "Items and Services" and "Because" box area. On the CMS-R- 131 L form, providers are allowed to customize the header, the reasons, and tests three-column box area. Both of these forms can be downloaded from the MedLearn page on the CMS Web site at: www.cms.hhs.gov/medlearn.

Providers should issue an ABN, form CMS-R-131 G or L, when they have a reasonable expectation that the services will be denied by Medicare. This could be due to information obtained from a Local Medical Review Policy (LMRP), National Coverage Decision (NCD) or other Medicare ruling. Submit charges for services where an ABN was issued with Occurrence Code 32 on the claim. All services on claims with Occurrence Code 32 must be covered charges, even if the provider expects that the services will be determined to be non-covered by Medicare at a later date.

Providers must give separate ABNs for different procedures if performed on different dates. The services and dates the ABNs were given should be shown on separate bills for each date involved. The one exception is that only one ABN is required for a series of services given under standing orders.

When a service not pertaining to the ABN was rendered during the same period as the service requiring an ABN, the services must be submitted on separate claims, and the statement dates of these claims cannot overlap. If the time periods cannot be separated (i.e., a service requiring an ABN is given on the same day as a service not requiring an ABN), a single claim must be submitted. The claim should only be for the overlapping period, reported with Occurrence Code 32, and showing all services as covered. Place modifier -GA with the Healthcare Common Procedure Coding System (HCPCS) code to identify the service (revenue code) line for which the ABN was given. Since this is an exception process, providers are reminded to use this mechanism only when it is impossible to separate the billing periods.

When there is uncertainty as to whether the services are covered by Medicare, the provider should inform the patient that Medicare might not pay for the services. Informing the patient does not mean issuing a CMS-R-131 form.

If the patient makes the decision to receive the services, but requests Medicare to make a medical coverage determination, submit the claim as a demand bill. Submit services in question on a separate claim with Condition Code 20 and report all charges as non-covered.

If the patient makes the decision to receive the services, but requests that the charges be submitted to Medicare for a denial, possibly for another insurer, submit the claim as a request for a denial. Submit services in question on a separate claim with Condition Code 21 and report all charges as non-covered.

If additional services are rendered on the same day as a non-covered service for which an ABN was given, and at a later time the provider determines that an ABN should have been given for another non-covered service, but wasn't, the provider should submit all charges on one claim. The covered services and the non-covered service for which the ABN was given should be submitted as covered, along with modifier -GA on the line item for which the ABN was given. The non-covered service for which no ABN was given should be submitted as non-covered. This service will be denied as "provider liable."