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The Advance Beneficiary Notice of Noncoverage Explained
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Pre-Quiz (see the end of this article for answers)

  1. The Advance Beneficiary Notice of Noncoverage (ABN) is an official document for which payer?
  2. True or false: The ABN is required for refraction services.
  3. Can I alter the ABN form to fit my needs?

When there is a doubt whether Medicare Part B will cover a service, it is always best to obtain an ABN from the patient before performing the services. Instances in which there would be doubt include uncovered diagnosis code, an oculoplastics procedure that may be determined to be cosmetic rather than medically functional or when frequency is exceeded. Certain services are considered statutorily excluded and do not need an ABN signed in advance from the patient. These include refraction services, routine vision care, cosmetic surgeries (including LASIK) and off-label/noncovered services. 

In 2011, CMS released an updated version of form CMS-R-131 — the ABN — to replace the 2008 version of the same form. The only difference is the “3/11” release date at the bottom, but you should use the new form.

On the form, 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.

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.

When you present your patient with the ABN form, tell them why the service may not be covered. Be sure to add modifier –GA to the CPT code on your super bill or in your electronic health record system. The –GA modifier notifies Medicare that a signed ABN is on file. If you forget to add the –GA modifier to the CPT code, Medicare will notify the patient that they are not responsible for payment of the service, with a statement that they should have been notified by the physician of possible noncoverage.

Since CMS approved and created the ABN form, you cannot alter it in any way.

Post-Quiz

  1. The ABN is an official document from Medicare Part B.
  2. False. Refractions are statutorily excluded and therefore do not require an ABN signed by the patient.
  3. It is not appropriate to alter the ABN form, as it is created and approved by CMS.

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About the author: Jennifer Arbuckle, CPC, OCS, is an Academy coding specialist whose background includes coding, billing, compliance and reimbursement in both a small private practice and a large academic medical institution. 

 
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