MAY 04, 2017
How to Use the ABN, 2017 Edition
Effective June 21, CMS requires all practices to use an updated version of form CMS-R-131, known as the Advance Beneficiary Notice or ABN. The new version replaces the 2011 form. The content of the form remains the same, but the expiration date in the bottom left corner has been changed to 03/2020.
In addition to making sure your practice uses the new form for all dates of service June 21 and after, the change is a good opportunity to review appropriate use of the form.
When you need to get an ABN
You should obtain a signed ABN from a Medicare Part B patient when you’re not sure about frequency or diagnosis coverage. When determining if Medicare Part B covers a service, you should first look for a policy.
Cases where coverage is unclear include:
- Uncovered diagnosis code;
- An oculofacial procedure that may be deemed cosmetic rather than medically necessary;
- A service provided more frequently than CMS covers.
Services considered statutorily excluded do not require a signed ABN. These include:
- Refraction services;
- Routine vision care;
- Cosmetic surgeries (including LASIK); and
- Off-label/noncovered services.
What the ABN does
If the service merits such documentation, the ABN form formally tells patient they may be responsible for the service if Medicare does not pay. Always educate the patient on why the service may not be covered.
The form also documents which of three options the patient desires.
Option 1: The service as outlined, billed to Medicare.
- The provider may ask to be paid now, but also agrees to bill Medicare for an official decision on payment, sent to the patient on a Medicare Summary Notice.
- The patient consents to payment if Medicare doesn’t pay, but can appeal Medicare’s decision by following the directions on the MSN.
- If Medicare does pay, the provider refund any initial patient payments, less co-pays or deductibles.
Option 2: The service as outlined, paid by the patient.
- The provider may ask to be paid now and does not bill Medicare.
- The patient cannot appeal, since the practice did not bill Medicare.
Option 3: Patient declines the service as outlined.
- The provider does not perform the service.
- The patient has no payment obligation and cannot appeal to see if Medicare would pay.
ABN best practices
- Don’t alter the ABN cannot in any way, otherwise Medicare may not accept it.
- Fill out each section, including the practice and patient information.
- Have the patient sign the form once s/he makes a decision.
- To ensure your claim is processed correctly, append modifier -GA to the CPT code. Modifier -GA notifies Medicare that you obtained a signed ABN. Without the modifier, Medicare will notify the patient that they are not responsible for payment of the service; the physician should have provided a statement of possible noncoverage.
- Once you implement the new version, make sure to remove all other versions from the practice. CMS will only accept the current version will be accepted.
- Do not apply this form to other payers; they may have their own forms or require your practice to create your own. Confirm with each payer; there is no consistency.