Medical Review Frequently Asked Questions (FAQs)

Q1. Under what circumstances should I use an ABN for a Medicare patient?
A1. You must issue an ABN:

  • When a Medicare item or service is not reasonable and necessary under Program standards, including care that is:
    • Not indicated for the diagnosis, treatment of illness, injury, or to improve the functioning of a malformed body member
    • Experimental and investigational or considered research only
    • More than the number of services allowed in a specific period for that diagnosis
  • When providing custodial care
  • When outpatient therapy services exceed therapy threshold amounts
  • Before caring for a patient who is not terminally ill (hospice providers)
  • Before caring for a patient who is not confined to the home or doesn't need intermittent skilled nursing care (home health providers)
  • Before providing a preventive service we usually cover but won't cover in specific situations when services exceed frequency limits
  • Before providing a Medicare item or service we will not cover (DMEPOS suppliers) because the:
    • Provider accepted prohibited unsolicited phone contacts
    • Supplier hasn't met supplier number requirements
    • Non-contract supplier provides an item listed in a competitive bidding area
    • Patient wants the item or service before the advance coverage determination

We may hold you financially liable if you do not give the patient an ABN in these situations.

Do not use an ABN for Medicare Advantage (Part C) or Medicare Prescription Drug Benefit (Part D) items and services.

You do not need to notify the patient before you provide items or services that are not a benefit or never covered. Section 20.2 of the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 30 has a list of items and services Medicare does not cover.

We recommend issuing a voluntary ABN or a similar notice as a courtesy to alert the patient about their financial liability.

An ABN is valid if you:

  • Use the most recent version approved by the Office of Management and Budget (OMB)
  • Use a single ABN for an extended course of treatment for no longer than 1 year
  • Complete the entire form
  • Ensure the patient understands the notice

What if the Patient or Their Representative Refuses to Choose an Option or Sign the ABN?
If the patient or their representative refuses to choose an option or sign the ABN, note the refusal on the original ABN. You can list refusal witnesses, but it is not required. If a patient refuses to sign a properly issued ABN, consider not providing the item or service unless the consequences (health and safety of the patient or civil liability in case of harm) prevent it.

Q2. What documentation is required to support the medical necessity for a non-emergent ambulance transport?
A2. Nonemergency transportation by ambulance is appropriate if either: the beneficiary is bed-confined, and it is documented that the medical condition is such that other methods of transportation are contraindicated; or, if his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. Medical records signed by a licensed, certified, medical professional, from outside the billing supplier/provider, must be submitted to corroborate the physician certification statement and support medical necessity.

The following notes may be submitted for the review: history and physical, progress notes, visit notes, encounter notes, office notes, physical or occupational therapy notes or any other type of medical record of the services provided by a physician or other licensed/certified medical professional (LCMP) from outside the billing supplier/provider.

Q3. I have a patient who is being seen and then is unable to attend therapy for a time, do I charge them a re-evaluation? Also, I have a patient being treated for their knee and now the physician would like their wrist assessed, do I charge them a re-evaluation?
A3. 97164: A re-evaluation is only allowed if there is a significant change in the beneficiary and/or the plan of care. To meet Medicare's medical necessity standard the medical record must support that the patient had an unanticipated significant change in their status or condition that required additional evaluation and/or assessment services. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. Medicare's medical necessity standard is not met in instances when the documentation supports that time was spent simply gathering data to show that the patient was i.e., making progress as anticipated in accordance with the plan of care. If the patient doesn't specifically need the additional assessment/evaluative services, then the service minutes are not covered and are not separately reimbursable.

Note that a re-evaluation (CPT 97164) is an untimed code, and these minutes must not be counted as time-based treatment minutes – they don't meet the code descriptor requirements. The code is appropriate if the long-term goals have to change due to the patient's condition.

10th visit progress reports are often routine re-assessments of the patient's progress in accordance with the plan of care and minutes spent providing this service typically do not meet Medicare's medical necessity standard and are not separately reimbursable.

Q4. I received a denial for insufficient documentation. I did not know that I needed to include the information in my documentation, can I add an addendum to my original documentation and resubmit it for review?
A4. No. Documentation must be already existing and cannot be newly created. Adding or altering existing documentation, especially following a notice of review (additional documentation request (ADR) letter) or payment determination based on medical review, is not appropriate and could be construed as fraudulent behavior. Addendums are used to provide information that was not available at the time of the original entry. Addendums should be timely and include the current date, reason for the addition/clarification of information being added to the medical record and signed by the person making the addendum. Documentation must also clearly identify all original content. Refer to:

Q5. What are the requirements when billing HCPCS G2212 for office visits billed with procedure codes 99205 and 99215?
A5. This code is used to report prolonged time and is only used when the primary evaluation and management service has been selected based solely on time. For an established patient, documentation must indicate at least 15 full minutes was spent past the maximum time that is required to report the highest level of service. This would mean that at least 69 minutes would need to be documented as the maximum time for CPT 99215 is 54 minutes. (54+15=69). For a new patient, the time requirements must be 15 full minutes or more past the maximum time for CPT 99205. This would mean that documentation would need to indicate at least 89 minutes was spent for the visit as the maximum time for this code is 74 minutes. (74+15=89). For each additional unit billed for HCPCS G2212, an additional 15 full minutes would need to be spent for the visit. Refer to: chapter 12 in the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12 - Prolonged Office Visits

Last Updated Mar 29 , 2024