By Evan M. Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA
December 22, 2016
Q: What is the ABN form used for?
A: The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For example, the provider may believe that the services will not be considered medically reasonable and necessary per Medicare guideline.
Q: When are ABNs mandatory for use?
A: According to Medicare rules, the ABN is the required method for communicating to Medicare patients their personal responsibility for payment of services received. To be clear, the ABN is mandatory for use only for services generally covered and governed by Medicare that may likely be or will be deemed "not reasonable and necessary". This allows the patient the opportunity to make an informed decision regarding receiving and paying for these services.
Q: Can ABNs be used to communicate Medicare non-coverage / non-payment of other non-covered services?
A: Yes they can. To a medical practice, this would be considered "voluntary ABN use". ABNs are used by practices that elect to do so, though it is not mandatory, to identify services or items that are not covered by Medicare or statutorily excluded from Medicare benefits.
In years past, Medicare did have a separate form that was required for use to report these non-covered and excluded services. That form however, has long since been retired. With the retirement of this form came the "voluntary ABN use" description as noted in the paragraph above. Practices that elect to not use the ABN for this purpose described above, often put verbiage relating to Medicare coverage and benefits onto the practice Financial Policy so as to inform Medicare patients and obtain acknowledgment of patient responsibility for non-covered items and services.
The method that individual practices elect to use in order to communicate the limitations of Medicare coverage and patient responsibility for these items or services should be clear. Patients should not be left to assume or guess what may or may not be covered by Medicare. Preserving patient relationships and avoiding misunderstandings, mis-communications, and patient complaints is an essential component in protecting a practice from other liabilities.
Q: When do I use an ABN form?
A: The ABN must be provided to the patient befor the non-covered service is provided. Otherwise it is invalid, which means that the provider would not be entitled to collect payment directly from the patient for the non-covered service. A description of the service(s) rendered, the reason Medicare may not or will not pay, as well as the estimated cost, is required to be properly disclosed.
Q: Can I offer the ABN to everyone just in case?
A: Medicare Learning Network ABN Booklet ICN 006266 states on page five that we are prohibited from issuing ABNs on a routine basis (that is, where there is no reasonable basis to expect that Medicare may not cover the item or service). Simply stating that Medicare could deny anything anytime is not a "reasonable basis". A "reasonable basis"' would be that you know Medicare's guidelines and the questionable service does not meet them.
Using a "blanket" ABN is not permitted. An example of a "blanket" ABN would be identifying multiple services on an ABN "just in case" they are rendered to a Medicare patient. Having all Medicare patients sign an ABN, again, "just in case", would also be considered a "blanket" ABN.
Q: Do I have to use the ABN form?
A: Practices are required to adhere strictly to Medicare guideline and rules if treating Medicare patients as either a par or non-par provider. The ABN must be used when applicable and the guidelines for proper use of the ABN must be followed for enrolled providers.
Q: How often does an ABN need to be updated?
A: According to the Medicare Claims Processing Manual (Chapter 30) and MLN booklet ICN006266 "providers may issue a single ABN to a patient receiving the same service multiple times on a continuing basis. ABNs for a repetitive service can be effective for up to one year." The ABN for ongoing services must describe the services rendered. If the delivery of the repetitive service exceeds one year or if the service provider changes, a new ABN must be issued. If a different service is provided than that identified on the already signed ABN, a new ABN must be issued for that new service.
Q: Where can I learn more about using ABNs?
A: The ABN form and instructions can be obtained directly from Medicare by visiting medicare.gov and searching for ABN. This includes both Spanish and English versions of the ABN as well as Medicare's own instruction manual. You can also search your local Medicare carrier website for publications relating to the ABN.
It is important to note that the ABN form being used must be the most current available. The most recent update to the ABN was mandatory for use in 2011 and is the CMS-R-131 version of the form. This version number is listed on the lower left corner of your ABN form. Any earlier version being used now is not considered valid by Medicare.