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Accuracy or Abuse? Appropriately Applying the ABN
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More paperwork. Just what the patient and the office needs. Yet the Advance Beneficiary Notice (ABN) is a crucial safety net for payment when used correctly. This article is designed to set the record straight on instances where it is appropriate to use the ABN and when it is not.

The Advance Beneficiary Notice of Noncoverage became mandatory on March 1, 2009. This form replaced the former Advance Beneficiary Notice (ABN-G) and Notice of Exclusion of Medicare Benefits (NEMB).

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It is a document designed by CMS and should be used when there is a belief on the practice’s part that they may have an issue getting paid for services rendered to Medicare beneficiaries that are considered to be limited: based on diagnosis coverage; and/or frequency of the service performed.

There are three options for the patient to choose:

Option 1. I want the service as outlined. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

Option 2. I want the services as outlined, but do not bill Medicare. You may ask to be paid now, as I am responsible for payment. I cannot appeal if Medicare is not billed. I understand with this choice I am responsible for payment, and I cannot appeal to see if Medicare would pay.

Option 3. I don’t want the service as outlined. I understand with the choice, I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

The form has a mandatory field for:
  • The description of the service(s) provided;
  • A reason Medicare may not pay; and
  • Cost estimates of the items/services to be performed.
The ABN language cannot be altered. It is available in English and Spanish under Coding Tools on the AAOE website. 

Be sure to append modifier -GA to the claim to alert Medicare that the ABN is on file in your office. Should you forget to append modifier -GA, the patient’s MSN will state, “You should have been told that Medicare may not cover this service. Therefore, you are not responsible for payment.”

ABN Quiz

To help you identify different ABN scenarios, take this quick quiz. Answer True or False to the following questions:

  1. An ABN is required documentation for a refraction.
  2. Use of an ABN is strongly encouraged when performing upper lid blepharoplasties that you believe to be functional.
  3. An ABN should be obtained for blepharoplasties that are clearly cosmetic.
  4. When submitting a claim with modifier -GY, offices must have an ABN on file.
  5. You’re not sure if a particular diagnosis code is covered for a test you are performing. An ABN is recommended.

The answers are as follows:

  1. False
  2. True
  3. False
  4. False
  5. True

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About the author: This article originally appeared in the August and September/October 2010 issues of Coding Bulletin and was written by Academy Coding Executive Sue Vicchrilli, COT, OCS.

 
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