Everybody’s Favorite Form: New Advance Beneficiary Notice of Noncoverage (ABN) Form Begins in 2012
NOTE: We have just added an educational webinar on using the ABN form. This is an expanded webinar with 75 minutes of content and 15 minutes of Q & A with the attendees. Click here to go to our webinar page for more information.
CMS recently released an updated version of the Advance Beneficiary Notice of Noncoverage (ABN) (form CMS-R-131), which will replace the 2008 version of this form. The 2008 and 2011 ABN notices are identical except that the release date of “3/11” is printed in the lower left hand corner of the new version. The ABN is used by all providers, practitioners, and suppliers paid under Medicare Part B, as well as hospice providers and religious non-medical healthcare institutions (RNHCIs) paid exclusively under Medicare Part A.
Providers and suppliers may use either the 2008 or 2011 version of the ABN through the end of 2011; beginning Sunday, January 1, 2012, they must begin using the 2011 version. ABNs issued after Sunday, January 1, that are prepared using the 2008 version of the notice will be considered invalid by Medicare contractors. 2008 versions of the ABN that were issued prior to Sunday, January 1 as long-term notification for repetitive services delivered for up to one year will remain effective for the length of time specified on the notice.
Okay, here’s the good stuff that I get questions on all day every day – how do I use the ABN?
First, let’s understand WHEN you should use the ABN.
The ABN’s reason for being is to allow the physician practice to collect from the patient for services that the patient wants, but are not covered by Medicare. Practices are not expected to give ABNs to patients to cover services that are never covered (called statutory exclusions), however, many find that it helps the patients understand when they receive a bill for the service. (Note: you may collect in full at time of service if you so choose.) With 2011’s new wellness benefits, some of the primary reasons for using the ABN have gone away. Patients receive a Welcome to Medicare Visit (not an exam) within the first 12 months of the effective date of Medicare Part B coverage. Medicare beneficiaries are eligible for one Annual Wellness Visit (AWV) every 12 months after they have had Medicare Part B for more than 12 months. This is a “visit” and not a physical examination.
Here’s a good example of WHEN you would use the ABN.
A Medicare patient wants an EKG even though she does not have any diagnoses that would point to an EKG being medically necessary. She is not in her first 12 months of Medicare coverage, therefore she does not qualify for an EKG as a part of her Welcome to Medicare Visit (not an exam.) She believes there may be something wrong with her heart, even though she cannot name any symptoms that would warrant a diagnostic EKG. In this case, without a diagnosis to support the EKG, an ABN would be appropriate. You would advise the patient that Medicare may not pay for the EKG, in fact probably won’t pay for the EKG, and you complete the ABN, showing the patient what she will be paying out of pocket for the test. In the case of Medicare not covering the test, you may charge the patient your full rate for an EKG and are not restricted by the Medicare allowable. If the patient agrees to have the test and signs the ABN stating she understands she will be responsible for the cost of the test if Medicare does not pay, you will provide the patient with a copy of the signed form and will will attach the completed form to the patient’s encounter form so the EKG will be billed with the modifier “GA” which indicates an ABN was executed for a service that might be covered by Medicare. In the case where a service is never covered (i.e. statutory exclusions) your Medicare Administrative Carrier (MAC) may require you to append a modifer “GY” when an ABN is signed and on file.
The ABN should be scanned with the encounter form or any other financial paperwork from the visit so it can be retrieved if requested by Medicare during an audit. If you do not archive your paperwork electronically, you should file the ABNs alphabetically by patient name by month. You can also scan the ABN into your EMR.
What are statutory exclusions (services that are never covered) under Part B?
- Oral drugs and medicines from either a physician or a pharmacy. Exceptions: oral cancer drugs, oral antiemetic cancer drugs and inhalation solutions.
- Routine eyeglasses, eye examinations, and refractions for prescribing, fitting, or changing eye glasses. Exceptions: post cataract surgery. Refer to benefits under DME prosthetic category.
- Hearing aids and hearing evaluations for prescribing, fitting, or changing hearing aids.
- Routine dental services, including dentures.
- Routine foot care without evidence of a systemic condition.
- Injections which can be self-administered. Exceptions: EPO, and clotting factors.
- Naturopath’s services.
- Nursing care on a full-time basis in the home and private duty nursing. (Refer to benefits under Medicare Part A).
- Services performed by immediate relatives or members of the household. Services payable under another government program.
- Services for which neither the patient nor another party on his or her behalf has a legal obligation to pay.
- Immunizations. Exceptions: Influenza, Pneumovax and Hepatitis B .
- Wheelchair van ambulance services.
- Cosmetic surgery.
What services doesn’t Medicare cover that you would use an ABN for?
Services that are covered under the Medicare Program may be limited in coverage due to the following:
- Certain diagnoses – a service may be covered, but that coverage may be limited to certain diagnoses. For example, vitamin B-12 injections are covered, but only for diagnoses such as pernicious anemia and dementias secondary to vitamin B-12 deficiency.
- Frequency/Utilization parameters – a service may be covered, but that coverage may be limited if the service is provided more frequently than allowed under a national coverage determination (NCD), a local coverage determination (LCD), or a clinically accepted standard of practice. For example, a screening colonoscopy (G0105) may be paid once every 24 months for beneficiaries who are at high risk for colorectal cancer otherwise the service is limited to once every 10 years and not within 48 months of a screening sigmoidoscopy.
- Proven clinical efficacy – if a service is considered investigational, experimental, or of questionable usefulness, the service may be denied as not reasonable and necessary. For example, Acupuncture is considered experimental/investigational in the diagnosis or treatment of illness or injury. Claims will deny because procedure/treatment has not been deemed “proven to be effective” by the payer.
Probably the hardest question to answer is : WHO should be responsible for getting the ABN signed by the patient?
The Answer is : EVERYONE!
Remember, you can’t have a patient sign a “blanket ABN” to use any time Medicare denies a service as non-covered. That’s fraud. You cannot have the patient sign the ABN after the procedure or service is provided. That’s fraud, too. The only time you may get the ABN signed is before the patient receives the service and after you clearly explain what Medicare might not cover, why they might not cover it, and if they don’t cover it, what the cost will be to the patient.
The WHO is so hard because often the person who has the most knowledge about Medicare (your coder, biller, or manager) sits in the back of the office and might never even see the patient on their way in or out the office. Many practices have given up on the ABN process because figuring out the workflow can be challenging.
Don’t give up! You can implement ABNs in your practice and here’s how:
If you have an EMR, this is a slam dunk because your system should be preloaded with the Medicare service limitations and when you place an order for a service that may not be covered, your EMR should warn you and generate an ABN. Nice!
If you don’t have an EMR, follow these steps:
- Review the Medicare coverage guidelines and compile a list of services your group provides or orders.
- Print the list with price ranges on the back of the ABN form (turn them over and run them through your printer or copier). You can print your own ABNs with your services and prices, but if you have very many services, you may not have enough room on the ABN. You may also choose to have more than one preprinted ABN – one with labs, one with services.
- Have a full staff meeting to discuss the ABN and your plan to implement a program to use ABNs when appropriate. Discuss the Medicare guidelines and what services your practice provides and educate the staff on the circumstances for which an ABN is appropriate. EVERYONE needs to help each other learn and master ABNs. Make sure everyone understands that the ABN is not in place to take money from Medicare patients – it is an opportunity to educate the Medicare patient
- Create a custom chart for your group that combines the services you provide with the associated rules. Post the chart in each exam room, the lab, the check-out station, on the EKG or other medical test equipment and anywhere where an employee should stop and think “Do I need an ABN for this?” Make sure blank ABN forms are available nearby. If you dislike having charts everywhere, create a short word or phrase and print it on bright paper, then post it appropriately. It might be “ABN CHECK” or something like that. Every few months, move the paper to a different place in the exam room, etc. and/or print it on a different color paper. Make sure those most likely to identify the need for an ABN – physicians, mid-level providers, nurses, medical assistants, referral clerks, lab techs – know they can ask for help with the ABN process when they need it.
- Some in-house or referral lab systems also furnish ABN information for mismatches on lab services and supporting diagnoses. Make sure and check the lab system before you begin a service!
You can find information and a copy of the 2011 version of the ABN (form CMS-R-131) here under the “FFS Revised ABN” link.
Thank you so much Mary Pat. I tried and tried to get my clients to use this form. First words out of their mouths, have everyone sign this! SOmetimes its just getting through thick skulls. Thank you again
I think people can’t afford NOT to use this form!
Thanks for your comment.
Hi Mary Pat,
How do you handle recurrent service ABN’s?
If you have a patient coming in monthly for the same service and it will not be covered by Medicare, you can put the monthly visits together on one form, documenting that the patient plans to have this series of services and understands that Medicare will not pay for them. In the case where it is a planned set of services, you may use one form for up to 12 months of the same services or a series of consecutive services in a like-group of services. Make sure the cost for the entire set or span of services is represented on the ABN.
Is there a form that we can use for NON medicare patients so that if a service is not covered (in our case blephoplasty) they are responsible for the charge?
I’ve altered a Medicare ABN so it can be used for any other payer. There is room for you to print this out on your practice letterhead. I will email it to you and anyone else who wants one can email me (email@example.com) for a copy.
Hi Mary Pat,
Can you e-mail the NON-Medicare ABN also? We’re an ENT practice that does functional but also cosmetic procedures.
thanks so much,
I am sending you the non-Medicare ABN right now.
Thanks for being a MMP reader.
Please settle a debate that is going on in our office regarding the new request for records from Medicare on all E&M codes billed with 24 modifier prior to payment. Can you use an ABN for an office visit (or surgery) that is in a global period “just in case Medicare denies the claim” based on the statement “we believe Medicare may not pay for an item or service?”
This is a great question! The only time you should use an ABN is when you will be billing the patient for a non-covered service. For Medicare this is either for a service that Medicare never covers, or for a service that Medicare only covers at certain frequencies, for instance once every 2 years.
You would not be billing a Medicare patient for a service performed during the global period UNLESS it fell into one of the two categories above, but I don’t think that is what you’re talking about. If Medicare does not pay for a service in the global period because it is considered part of the global period, you cannot bill the patient for that service. You would be appending the modifier GY to the code to notify Medicare that you have an ABN on file, and they would quickly let you know that the beneficiary could not be billed, and that in fact, you are misusing the form. It could even raise a red flag and be the catalyst for an audit as Medicare is cracking down on services considered part of the global period, but billed with a modifier 24.
Short answer – do not use an ABN for this purpose!
Thanks for the info it was very helpful! However, I had a patient come in the office back in August and she had paid for her glasses. Yesterday she came in and told the staff that we were suppose to bill Medicare for her glasses and she wanted her money back. We told her that she did not inform us of billing Medicare the day she got her glasses, but we would in fact bill Medicare for her. We asked her to sign the ABN and she refused to sign the ABN. What modifier should I use or how would I go about filing this claim.
I am guessing that the glasses coverage is an expanded benefit through a Medicare Advantage Plan. If so, and the patient did not ask you at the time to bill Medicare, you did nothing wrong.
I suggest you file the claim and see if you can either assign the benefits to the patient, so she will receive the check from Medicare and you can refund her the difference, OR or file the claim, post it to your system and create the refund at that time when Medicare has paid you and you can give the patient back her money, less any deductible or co-insurance.
My question is this:
I can not find it on the Medicare website either to confirm or deny the practice.
Can you have an ABN signed by a patient who is physically able to come into the office daily for iv infusion therapy and they are sent home with the drug that Medicare would cover in office? If the dole purpose is the have Medicare deny the claim with a PR in order to bill the secondary 100% of billed charges?
To me this seems wrong if not shady? If Medicare pays the drug normally and may pay it under the part d benefits (perhaps at a lower reimbursement) then purposely asking for a PR denial because the place of service (12) is not covered but the drug is fraud, correct?
Place of service 12: does this require a provider, pa, or nurse to go to the home ever?
Secondary payer: is it legal to request the PR denial with an ABN just to have the secondary pay as primary? If billed as is without an ABN or modifier requesting a denial the denial is a CO and the secondary denies it as well because Medicare denied it. Wouldn’t it be fraud to purposely ask Medicare to give a PR denial just to make the secondary pay when normally they wouldn’t based on the Medicare denial for the place of service not the drug itself.
ABN: if the ABN is considered invalid due to either being on the wrong form or being filled out incorrectly then are you allowed to have the patient sign a new one months or years later AFTER the procedure or service was furnished and attach it to the incorrect one as an amended ABN? Or does invalid mean that if you did it incorrectly that any monies paid by the patient and perhaps the secondary should be refunded since the notification was invalid?
Also regarding ABN’s if the patient does not have the same copy as the practice then isn’t it considered fraud as well? (i.e. practice neglects to obtain an ABN and Medicare is requesting one so patient is asked to sign and an employee of the practice instructs the patient not to date the ABN but gives them the copy undated yet applies a date after the signature and submits it to Medicare to prove it was received prior to the service being rendered)
#1 – “Patient receiving infusion services at home instead of in the office” – The service must be delivered at the lowest possible level of service that is appropriate for the patient. If any information is falsified, or if the service is not delivered at the lowest cost to Medicare, or has been gamed to maximize the revenue inappropriately, it would be considered fraud.
#2 – “Place of service 12: does this require a provider, pa, or nurse to go to the home ever?” A Part B professional service at POS 12 must be rendered by a physician, MLP, unless you are talking about a home health service. Home health patients must not be able to come to a facility to receive services.
#3 – “Is it legal to request the PR denial with an ABN just to have the secondary pay as primary?” Yes, there are situations where the payer denial is needed to file the secondary insurance. Primary insurance must always be filed first, so it must be filed to get the denial. The secondary may not necessarily deny because the primary did (if you are talking about regular insurance vs. supplemental insurance) if the benefits and guidelines are different.
#4 – ABN – The ABN must be the correct form in force by CMS at the time the ABN was given to the patient to sign. If you did not use the correct form, or the form was not filled out correctly, it is invalid. You should refund any money collected from the patient under that form as it is invalid. The second, however, would not need to be refunded if it was paid as the ABN for medicare does not apply to the secondary. The ABN Medicare must be the original with the patient’s signature and must match the copy you gave the patient.
Good morning, I came across your site when trying to find an answer to an ongoing problem that we are experiencing and wondered if you have a suggestion. We have Medicare patients scheduling appointments for an annual exam and when they present are checking Option 3 on the ABN that they do not want the service, of course then we are denied by Medicare when the provider performs and bills for the service. I relaize that part of the issue is that there is a disconnect when the nurse begins the note as Health Maintenance and the provider follows the flow of that visit since this is actually what the patient has scheduled her appointment for…are others experiencing this same problem? Any ideas, suggestions. Thank you for your time. Dawn
This is a very common problem right now and it’s primarily because the patients doesn’t understand the choice of visits, and often the staff scheduling the appointment do not understand either.
At the time the patient asks for an annual exam, the scheduler needs to explain that Medicare does not pay for an annual wellness exam, but that they do pay for an annual wellness visit, which does not include a physical examination. If the patient insists that they want the annual exam and that they will pay for it themselves (make sure to quote the price to them), they have to complete the ABN before the visit and they must check on the form that they want the service. If they check that they do not want the service, there is no option but to cancel the visit.
Of course, canceling the visit doesn’t help anyone! Some physicians will perform a full physical exam during a sick visit, and others will perform a full physical exam during the wellness visit. Needless to say, neither of these solutions is right from Medicare guidelines, but it is very hard to reconcile what patients want with how the Medicare guidelines are written.
The best solution is to educate patients about their choices and get the ABN signed correctly.
I ran across this site while searching for answers to some questions I have. I am a Phlebotomy Supervisor for a well known Laboratory, and the new billing supervisor and I have been meeting about ABN’s and the importance of getting knowlegde to the Phlebotomists and patients. Our one question that we can not seem to agree on is: Are we to have patients sign an ABN waiver if the patient has a medicare advantage insurance (such as Humana, Aetna, AARP,Regence Etc)?
We have some of our phlebotomists that will not have the medicare advantage patients sign a waiver. I do not want to go to them with misleading information if they are correct.
Most Medicare Advantage plans follow the same general guidelines as traditional Medicare. The point of the ABN is to protect the patient from being hit with fees that they are not expecting, but I see it as protecting the organization as well. When you take the time to explain things to the patient and have them sign the ABN, you are educating the patient and protecting your payment at the same time. I suggest you implement a policy that all Medicare-type patients will sign ABNs for any labs that might not be covered by Medicare or Medicare Advantage plans based on medical necessity (patient requests) or frequency limitations. Unless you hear specifically from the payer that they do not adhere to the Medicare guideline of using the ABN, I would use the ABN when appropriate.
Thank you for your response Mary Pat. It does make me feel somewhat better that we are not the only ones with this issue. I do agree that a lot of it is patient education and hopefully we can help the patient to better understand.