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Savvy Coder: Coding & Reimbursement
A Quick Guide to the ABN Form
By Sue Vicchrilli, COT, OCS, Academy Coding Executive
 
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(PDF 121 KB)

Do your Advance Beneficiary Notice of Noncoverage (ABN) forms have “3/11” printed in the lower left-hand corner? Good. You are using the up-to-date version published by CMS last spring. It is essentially the same as the old version of the form, and the rules on its use are unchanged. Read this quick overview of the ABN to ensure your practice is using the form appropriately.

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What is the purpose of the ABN?

You use the ABN to inform patients of their potential financial responsibility when you know or suspect that Medicare will not cover an exam, test or surgery. Typical examples include a noncovered diagnosis code, performance of a test exceeding frequency edits, or an oculoplastic procedure that may be deemed cosmetic rather than functional. In such cases, the ABN serves as proof that the patient had knowledge, prior to receiving the service, that Medicare might not pay.

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Which payers recognize the ABN?

According to the CMS, ABNs are only provided to beneficiaries enrolled in original Part B Medicare.

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When should an ABN be given?

The ABN should be presented to the patient prior to providing care. Patients can then make an informed decision about whether to receive services and accept financial responsibility if Medicare does not pay. If the physician’s practice does not deliver a valid ABN to the patient, the patient can’t be billed for the service. However, there is an exception: An ABN is not required in order to bill a patient for an item or service that is not a Medicare benefit and thus is never covered—such as a refraction or cosmetic surgery.

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Use modifier –GA.

Modifier –GA on the CMS 1500 form tells Medicare that a valid ABN is on file. Without modifier –GA, the remittance advice (RA) to the patient—formerly known as the explanation of benefits (EOB)—will state: “You should have been told that Medicare may not cover this service. You are not responsible for payment.”

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Can you alter the ABN form?

No. It is a Medicare-approved form and it cannot be altered.

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Use of ABNs is mandatory.

The ABN is used by all providers, practitioners and suppliers paid under Medicare Part B, as well as hospice providers and religious nonmedical health care institutions paid exclusively under Part A.

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MEET THE NEW ABN, SAME AS THE OLD ABN. Last year, CMS released an updated version of form CMS-R-131—the Advance Beneficiary Notice of Noncoverage (ABN)—to replace the 2008 version of the same form. The 2011 version of the ABN notice is identical to the 2008 version except that it has the release date of “3/11” printed at the bottom.

You already should be using the new form. CMS initially announced that providers and suppliers must start using the revised ABN no later than Sept. 1, 2011. It subsequently postponed that date to Jan. 1, 2012, so providers and suppliers with preprinted stockpiles of the old ABNs would have time to exhaust their supplies.

Download the new ABN in English or Spanish. Go to www.aao.org/coding and select “Coding Tools” and then “Revised Advance Beneficiary Notice (ABN).”

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