Coding and Reimbursement
New Rules for ABNs
Medicare has finally made its own ABN form official. Here's how to use it correctly.

BY SUZANNE L. CORCORAN, COE

Starting last year, Medicare introduced its own Advance Beneficiary Notice (ABN) form on a trial basis. As of October 1, 2002, that form -- CMS form CMS-R-131-G -- becomes official, and all practices are required to use it when providing certain services to Medicare patients.

The form is intended to ensure that a patient is aware that Medicare is likely or certain to deny the claim for an item or service you're planning to provide. By signing the ABN, the Medicare beneficiary acknowledges that he or she has been advised that Medicare is unlikely to pay, and agrees to be responsible for payment.

The same form is used for professional services, ASC facility fees, and postcataract eyeglasses.

Q: How should we use the ABN form? Requirements include:

• Always get the ABN signed before providing the item or service.
• Use the CMS form for Medicare patients only. (This should include those who have Medicaid coverage.)
• Submit your claim with modifier -GA added to the appropriate CPT or HCPCS codes.
• Use an ABN for both assigned and nonassigned claims, as well as for dispensaries that don't have Medicare supplier numbers.
• You don't need an ABN for services that are statutorily (by law) non-covered by Medicare, such as refractions, cosmetic surgery or extra pairs of eyeglasses or contact lenses for pseudophakic patients following cataract surgery.

Q: What happens if I don't get a signed ABN? If you don't have a signed ABN and Medicare denies the claim, the beneficiary isn't required to pay you. Any money you've collected must be refunded within strict time limits, unless you successfully appeal the denial.

Q: What if the patient won't sign an ABN? You're not obligated to provide items or services to a Medicare beneficiary who refuses to sign an ABN, except in the case of an emergency.

Q: May I modify the ABN form? Yes; some modifications are required.

• You must add your name, address and telephone number at the top.
• You may add your practice logo.
• The "Items or Services" and the "Because" boxes are for your use. You can include preprinted checklists to simplify providing the information.

Note: You may not alter any other portion of the form, and the form must be on one single-sided page, even with your additions.

Q: What about filling out the form? To complete the form:

• Fill in the patient's name and Medicare number at the top of the form.
• Complete the "Items or Services" box with a description or listing of the services (professional and/or ASC) or optical features. The description must be easy to understand and complete.
• Complete the "Because" box with reason(s) why you think Medicare will deny your claim. Reasons must be clear and understandable by the patient. General statements such as "medically unnecessary" are not acceptable.

Other important points:

• The ABN must be signed and dated to be valid.
• Get the ABN signed before providing items or services.
• The patient must personally choose Option 1 or Option 2.
• Completing the "Estimated Cost" field is optional. (Don't include the cost of any covered items and services.)
• You must give the patient a legible copy of the completed and signed ABN. You keep the original.
• Both the copy and original should be blue or black ink on white paper.

Q: Must I always file a claim? Yes. Effective October 1, 2002, HIPAA requires you to file a claim any time the patient signs an ABN.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800)399-6565 or via e-mail at scorcoran@corcoranccg.com.