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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.

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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:

  1. Review the Medicare coverage guidelines and compile a list of services your group provides or orders.
  2. 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.
  3. 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
  4. 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.
  5. 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.




The ABN: The Most Misunderstood and Underutilized Document in Healthcare

There’s a new ABN form required to be in use in January 2012 – read about it here in my article “Everybody’s Favorite Form: New Advance Beneficiary Notice of Noncoverage (ABN) Form Begins in 2012”

Note from Mary Pat: The Advance Beneficiary Notice of Noncoverage (ABN) is a collection tool that many medical practices do not know how to implement.  It is particularly difficult to determine who has ownership of this process, because the form must be completed and signed by the patient before the service is provided.  The patient is in the exam room or the lab, ready for the service or test, and a knowledgeable staff person must step in, explain the rules and pricing and obtain the patient’s signature.

Blogger Charlene Burgett does a great job of explaining the ins and outs of using the ABN, and has agreed to share an article originally published on her blog “Conundrum” with MMP readers.

Charlene

The use of the ABN is required by Medicare to alert patients when a service will not be paid by Medicare and to allow the patient to choose to pay for the service or to refuse the service.

If the practice does not have a signed ABN from the patient and Medicare denies the service, the charge must be written off and the patient cannot be billed for it. The only exception is for statutorily excluded services (those that Medicare never covers like cosmetic surgery and complete physicals for example). In this case, a practice can bill the patient for the non-covered service despite not having an ABN.  It is, however, a good idea to have the ABN signed for non-covered services so the patient is made aware that they are responsible.

If the patient signs the ABN and is made aware of their financial responsibility you may require the patient to pay for this service on the date the service is provided. You may also charge the patient 100 percent of your fee. You do not have to reduce your charge to the Medicare allowable.

With a signed ABN, the practice has proof of the patient’s informed consent to provide the service and their agreement to be financially responsible for the service. In the past, Medicare had a “Notice of Exclusion of Medicare Benefits” (NEMB) that we could provide to the patient (no signature required) to alert them of Medicare’s non-covered services. The ABN has replaced the NEMB.

The typical reasons that Medicare will not cover certain services and that would be applicable are:

  1. Statutorily Excluded service/procedure (non-covered service)
  2. Frequency Limitations
  3. Not Medically Necessary

Statutorily Excluded items are services that Medicare will never cover, such as (not a complete list):

  • Complete physicals (excluding Welcome to Medicare Screenings, with caveats)
  • Most immunizations (Hepatitis A, Td)
  • Personal comfort items
  • Cosmetic surgery

For these items, it is a good idea (not a requirement) to complete the ABN and have the patient check the appropriate box under options and sign the ABN. For the sake of the billing department, I strongly encourage the use of ABN’s for statutorily excluded items.

Frequency Limitations are for services that have a specific time frame between services. For example, Medicare allows one pap smear every 24 months if the pap is normal.  If the patient wants one every 12 months for their peace of mind, Medicare will pay for year one and the patient will pay for year two and that pattern continues. The ABN needs to be on file for the year that the patient is responsible for paying.  If the patient fits Medicare’s guidelines for “high risk” they are allowed to have the pap every 12 months and no ABN is required.

Services that are not considered Medically Necessary are those that do not have a covered diagnosis code based on Local Coverage Determinations (LCD).  One example is for excision of a lesion. If the lesion is being removed because the patient just doesn’t like how it looks, that is considered cosmetic surgery. If the lesion is showing some changes (i.e. bleeding, growing, changing color, etc), then it is considered medically necessary because it potentially can be malignant. The removal needs to have diagnosis coding to substantiate the medical necessity and Medicare has Local Coverage Determinations that list all the codes/coding combinations that Medicare will approve for payment.

A rule of thumb in trying to discern the necessity of ABNs is to ask yourself if there may be some times that the service isn’t covered by Medicare.  The times the service isn’t covered, an ABN is required. To illustrate this point, here are two examples:

  • EKGs are covered for certain cardiac and respiratory conditions. The only time an EKG is covered for preventive screening is during the patient’s first year enrolled in the Medicare program and when being done during the Welcome to Medicare screening.  After that time, Medicare will never cover an EKG for preventive screening. To notify the patient of this and to show that the patient agrees to be financially responsible for the EKG, an ABN should be completed.

 

  • Another example is for the Tetanus immunization.  Medicare will cover tetanus when medically necessary; if the patient has cut themselves and the tetanus is provided due to that injury.  If the tetanus is provided to the patient because it has been ten years since the last tetanus and the tetanus is not in response to a recent injury, then it will be non-covered because it is not “medically necessary” and the ABN will need to be on file.

ABNs need to be completed in their entirety.  The “Options” box can only be completed by the patient and it states that “We cannot choose a box for you”.  That would appear to be coercion.

A “blanket” ABN, one that is signed by the patient for all services provided within a certain time period, is not acceptable and is illegal.


In addition, there is a small area to provide additional information that can be used by either the patient or the provider’s office. This could be anything pertinent to the information that the ABN covers. The bottom of the form is where the patient signs and dates. We keep the original ABN in the chart behind the progress note for that day. Providers MUST provide a copy of the signed ABN to the patient.

The current ABN form with instructions can be found here.

If a service is denied by Medicare and the physician does not have a signed ABN prior to the service being rendered, the service can not be billed to the patient and will need to be written off.  Sometimes a patient may refuse to sign the ABN – if this happens it is appropriate for the physician to document the refusal and sign, along with having a witness sign.  Medicare will accept this and the patient can be billed for the service if denied by Medicare.

How does Medicare know whether or not you have a signed ABN?  You tell them, by adding a modifier to the CPT code when completing the claim form.  The appropriate modifiers are:

GA:  The ABN is signed, but the service may not be covered.

GY:  A “statutorily excluded” service.

GZ:  The service is expected to be denied as not reasonable or necessary.  This is typically used when there is a secondary payer that requires the Medicare denial before they pay benefits.

The use of the ABN is often misunderstood; however, it is the only way a patient can be informed about their financial responsibility prior to agreeing to a service being rendered.  This is an issue that the OIG has reportedly been interested in investigating for fraud and abuse.

Charlene Burgett, MA-HCM

Note: Readers, how do you make the ABN work in your practice?  Do you train the clinical staff, the physicians, or other staff to recognize the “ABN Moment”?  How do you make it work? Please share your ideas by responding with a comment.