ABN Issue - Form Populating in Error
Incident
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Investigating
S Situation
When scheduling Medicare Patients for specific exams, test, and/or procedure, there is a Medical Necessity check that is completed at the time of order entry. Currently, it has been discovered that there is an issue with the Medical Necessity check in PowerChart "failing", which then prompts the Advance Beneficiary Notice to be generated for the patient to sign. In some of these cases, the Advance Beneficiary Notice is not necessarily needed for an approved diagnosis code according to CMS's regulations.
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B Background
CMS requires that Medicare patients must have a Medical Necessity check completed before services are rendered. The Medical Necessity check is reviewing for an approved diagnosis code and/or frequency of the appointment. If this does not happen before the patient has services, the organization runs the risk of absorbing that cost. Medicare Patients are presented an Advance Beneficiary Notice at the time of arrival that includes price transparency about the appointment. The patient is able to make a better-informed decision about their care when this form is presented.
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A Assessment
It has been identified that there is an issue within the Medical Necessity check causing some appointments to "fail" for specific diagnosis codes. At the time of order entry, the physician/clinical has the opportunity to update to the correct diagnosis code for the specific procedure/test an Advance Beneficiary Notice will not populate for the patient to sign. However, it has been determined that there are some diagnosis codes that still "fail". Vendor resources have been engaged and are actively working on the issue.
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R Recommendation
The ordering clinician should review the CMS website to ensure the diagnosis code is correct. Once this has been reviewed a comment can be placed in the order comments. If the diagnosis code on the order is not correct according to the CMS website a new code should be selected and updated on the order. An encounter comment can then be placed by scheduling team of approval per CMS in which the CCI team will bypass the ABN. ABN’s will still be presented to patients for those still failing without an approval comment.
Here is the link for the CMS’s website:
https://www.cms.gov/medicare-coverage-database/search.aspx
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Please communicate this to staff.
When scheduling Medicare Patients for specific exams, test, and/or procedure, there is a Medical Necessity check that is completed at the time of order entry. Currently, it has been discovered that there is an issue with the Medical Necessity check in PowerChart "failing", which then prompts the Advance Beneficiary Notice to be generated for the patient to sign. In some of these cases, the Advance Beneficiary Notice is not necessarily needed for an approved diagnosis code according to CMS's regulations.
________________________________________________________________________________
B Background
CMS requires that Medicare patients must have a Medical Necessity check completed before services are rendered. The Medical Necessity check is reviewing for an approved diagnosis code and/or frequency of the appointment. If this does not happen before the patient has services, the organization runs the risk of absorbing that cost. Medicare Patients are presented an Advance Beneficiary Notice at the time of arrival that includes price transparency about the appointment. The patient is able to make a better-informed decision about their care when this form is presented.
_________________________________________________________________________________
A Assessment
It has been identified that there is an issue within the Medical Necessity check causing some appointments to "fail" for specific diagnosis codes. At the time of order entry, the physician/clinical has the opportunity to update to the correct diagnosis code for the specific procedure/test an Advance Beneficiary Notice will not populate for the patient to sign. However, it has been determined that there are some diagnosis codes that still "fail". Vendor resources have been engaged and are actively working on the issue.
__________________________________________________________________________________
R Recommendation
The ordering clinician should review the CMS website to ensure the diagnosis code is correct. Once this has been reviewed a comment can be placed in the order comments. If the diagnosis code on the order is not correct according to the CMS website a new code should be selected and updated on the order. An encounter comment can then be placed by scheduling team of approval per CMS in which the CCI team will bypass the ABN. ABN’s will still be presented to patients for those still failing without an approval comment.
Here is the link for the CMS’s website:
https://www.cms.gov/medicare-coverage-database/search.aspx
__________________________________________________________________________________
Please communicate this to staff.
This incident affects: Cerner applications (PowerChart, RevCycle, FirstNet, SurgiNet, etc).