Coding

Advance Beneficiary Notice 101

Here’s how to inform Medicare beneficiaries of noncovered services.

BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA

When your office performs noncovered services for Medicare beneficiaries, you need to be transparent and keep those patients informed that they may be financially responsible. Medicare’s (CMS’) formal document designed for this purpose, an Advance Beneficiary Notice of Noncoverage (ABN), is a written notice from a health-care provider to a Medicare (generally Part B for eyecare providers) beneficiary.

CMS recommends getting a signed ABN whenever you believe that Medicare is likely or certain to deny your claim for an item or service you plan to provide. By signing an ABN, the Medicare beneficiary acknowledges that he or she has been advised that Medicare will probably or certainly not pay. The beneficiary also agrees to be responsible for payment, either personally or through another insurance (including Medicaid).

An ABN is required for both assigned and non-assigned claims. The law requires that individuals or organizations that are not registered with Medicare as a provider, such as some optical dispensaries, also use the ABN.

Exceptions

You do not need an ABN for items or services that are statutorily (by law) non-covered by Medicare. Statutorily non-covered services in an eye-care practice include refractions, routine eye exams, most refractive surgery, cosmetic surgery, and the non-covered portion of deluxe IOLs (i.e., presbyopia-correcting and toric IOLs). Eyeglasses or contact lenses, outside of the limited benefit (i.e., one pair following each cataract surgery), are also statutorily excluded.

Instructions also allow you to issue an ABN voluntarily for items excluded from Medicare coverage. At your discretion, you may choose to notify beneficiaries that these services are never covered using the most current version of the ABN (March 2011).

Medicare Advantage Plans (Part C) have been instructed by CMS that the official ABN can’t be used. Check with the individual Part C plan for their process and/or forms. Private payers may have their own forms or processes.

Customization

I’m often asked, “Can we modify the ABN?” The answer is “A little bit.” (You can link to the ABN form and instructions on the CMS site [http://tinyurl.com/j2vjcph].)

You must personalize some things in the document, and you might choose to do others. You must add your name, address, and telephone to the header. You may add your logo and other information if you wish. The “Items or Services,” “Reason Medicare May Not Pay,” and “Estimated Cost” boxes are customizable, so you can add pre-printed lists of common items and services or denial reasons. Anything you add in the boxes must be high contrast ink on a pale background. Any other alterations to the form are not allowed. The ABN itself must be one page, single-sided, and the reverse side must be blank, but an addendum is acceptable.

You must complete your portion before asking the beneficiary to sign. Fill in the beneficiary’s name and your ID number (not HIC number) at the top of the form.

Complete the “Items or Services” box, describing what you propose. You must use language that the beneficiary or authorized signatory can understand. You may add CPT or HCPCS codes, but codes alone are not sufficient without a description. Complete the “Reason Medicare May Not Pay” box with the denial reason(s). The reason(s) must be specific to the situation; statements such as “medically unnecessary” are improper. The “Estimated Cost” field is required.

Options—the beneficiary’s role

The beneficiary must personally choose Options 1, 2, or 3 and should mark that area clearly. The patient or authorized legal signatory must sign and date the form before service delivery.

If the beneficiary chooses Option 1, you must file a claim and append an appropriate modifier to the reported item(s) or service(s). Modifier GA is used to denote a “waiver of liability statement issued as required by payer policy.” For example, the patient may desire an OCT when the reason is potentially not covered. You ask the patient to sign the ABN and submit your claim for that CPT code with modifier GA.

Option 2 on the ABN applies to situations in which Medicare is precluded from paying for the item or service and the beneficiary does not dispute it. It is not necessary to file a claim unless the beneficiary specifically requests that you do so; post the item or service and file the claim with modifier GY (“Item or service statutorily excluded or does not meet the definition of any Medicare benefit”) to designate there is no basis to pay.

If the beneficiary chooses Option 3, there is no claim or charge; the service is not provided.

Instructions most recently updated on October 2015 note that the ABN can be executed and saved electronically, but the beneficiary must be offered a paper version. The electronic ABN, if chosen, must be printed and given to the patient. Your paper ABN can be scanned/retained electronically after being signed and dated. Without proof of advance acceptance of financial responsibility, you will be required to make a refund.

Conclusion

Some services aren’t covered, and the ABN is the way Medicare Part B prefers that you notify beneficiaries. It’s important to understand how to fill it out and deliver it properly for it to be valid. Other insurers (including Part C) might have other processes and forms.

As always, “Good coding” to you! OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.