Coding & Reimbursement

The New ABN

By Suzanne L. Corcoran, COE

Medicare has just published a new Advance Beneficiary Notice (ABN) of Noncoverage form as part of its regular, 3-year update. Here is what you need to know.

Q. When should I use the new ABN?

A. CMS has published a new form (CMS-R-131), which is effective immediately. Its use is not mandatory until Sept. 1, 2008, but you should start as soon as possible.

Use the same form for professional services, ASC facility fees and postcataract eyeglasses. An ABN is required for both assigned and non-assigned claims; use it for Medicare patients only. You can access the new form and the instructions at http://www.cms.hhs.gov/BNI/Down loads/ABNFormInstructions.zip.

As before, get an ABN whenever you believe that Medicare is likely to deny the claim for an item or service that you are planning to provide. Always get it signed before providing the item or service. Submit your claim with modifier GA added to the appropriate CPT or HCPCS codes.

By signing an 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.

You do not need an ABN for services that are statutorily (by law) non-covered by Medicare. In an eyecare practice, these include refractions and cosmetic surgery. Eyeglasses or contact lenses for phakic patients, or pseudophakic patients in excess of one pair following each cataract surgery are also statutorily excluded.

The new form may also be used for these excluded services; CMS believes that this form should largely replace a Notice of Exclusion from Benefits (NEMB), although that form is still permissible if you prefer.

Q. May I modify the ABN form?

A. Yes. You must add your name, address and telephone at the top, and may add your logo. CMS has replaced the previous label, "Because," but the purpose hasn't changed. You may change the "Items or Services" designation if you wish. You may not alter any other portion of the form. The form must be on one single-side page.

Q. How do we complete the form?

A. Fill in the patient's name at the top of the form, exactly as it appears on the patient's Medicare card. There is also space for an optional identification number; the Medicare number is no longer to be used.

Complete the "Items or Services" box with a description or listing of the services or optical features you expect to be denied. The description must be easy to understand and complete.

Complete the "Reason Medicare May Not Pay" box with the reason(s) why you think Medicare will deny your claim. The reason(s) must be clear and understandable by the patient. General statements such as "medically unnecessary" are not acceptable. You must review the information verbally with the patient or his/her representative prior to signature.

The estimated cost of these items or services is now required. If there are multiple items or services, you may itemize or aggregate the estimated cost. Do not include the cost of covered services.

If more items or services need to be described than fit onto the ABN, you may use an attachment. Note in the box that an attachment exists; be sure to keep it together with the signed ABN form.

Other important points:

► Get the ABN signed before providing items or services

► The patient must personally choose an Option

► The ABN must be personally signed and dated by the beneficiary or representative

If you use checklists in the boxes:

► Be sure to check only planned items or services

► Check multiple reasons if they apply

► Add additional items and services or denial reasons when necessary.

You must give the patient a legible copy of the completed and signed ABN. You keep the original.

Q. Must I always file a claim?

A. Yes. Effective Oct. 1, 2002, HIPAA requires you to file a claim any time you get an ABN. If Medicare pays even though you have an ABN, refund the payment to Medicare.

Q. What happens if I don't get a signed ABN?

A. A Medicare beneficiary has no responsibility to pay you if Medicare denies a claim and you do not have a signed ABN. Any money you collected must be refunded unless you successfully appeal the denial. There are strict time limits for making refunds.

You are not obligated to provide items or services to a Medicare beneficiary who refuses to sign an ABN (other than in an emergency). OM