ED Coding and Reimbursement Alert

Know When an ABN Is Needed … and Why

Last year, the Centers for Medicare & Medicaid Services (CMS) released a new, updated ABN form to issue in the following circumstances:

• When you believe Medicare may not pay for an item or service;
• When Medicare usually covers the item or service; or
• When Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

By having the patient complete the ABN, you’re alerting them that they may have to pay you directly for the service. They can then decide whether they want to move forward with the service knowing how much it’s likely to cost them. If they don’t complete the form but they get the service from your practice anyway, you are unlikely to be able to collect directly from them.

Although not required, some experts also recommend getting an ABN even when you know Medicare statutorily doesn’t cover a particular service because it creates patient good will. This way, you notify the patient up-front that they’ll be responsible for a charge and how much they’ll expect to pay, ensuring that everyone is on the same page financially.

To ensure you complete your ABN properly, check out the following tips on how to complete a few of the most confusing fields on the form.

Learn the ABCs of ABNs

At the top of the ABN form, you’ll see Field “A,” which says “Notifier.” In that box, you must enter your practice’s name, address, and phone number. If this data is part of your standard logo, you can simply place your logo in the space. Your practice can pre-print this information on your ABN forms, hand-write it, type it, or use a label, sticker, or stamp.

You cannot, however, leave it blank or complete this part after the patient signs the ABN. The practice information must be on the form prior to giving the patient the ABN.

Describe the Service in Field “D”

Because field “D” is simply a blank box that appears in seven different places on the ABN form, some providers simply fill it in once and move on, but this field is crucial to complete in every location where it’s found.

Here, you’ll enter the specific names of the services, items, lab tests, procedures, equipment, or other type of service that you believe may not be covered by Medicare. If you think the service will be partially denied and not completely covered, you should list the component that may be denied.

In cases when the patient is likely to get the care more than once (for instance, repeated blood draws to monitor voluntary hormone replacement therapy), your practice should specify the frequency or duration of the items or services you expect to be denied.

To be considered a valid ABN, your practice must complete all seven instances of field D, including the one on the first line of the ABN, which says, “NOTE: If Medicare doesn’t pay for D.____ below, you may have to pay.”

In this smaller field, you might list “blood draws,” while in the larger box below it, you can elaborate more, such as “weekly blood draws to monitor HRT levels.”

You Must List a Reason for Noncoverage

In field “E,” CMS gives you an opportunity to list the reason that Medicare may not pay for the service. This is a mandatory field, and you can use whatever terminology you’d like, as long as it’s language your patient would understand. For instance, you should avoid technical terms like, “BID injections subject to denial.” Instead, you’d say, “Due to frequency limitations, Medicare won’t pay for injections given twice a day.”

In CMS’ ABN Form Instructions, the agency lists three of the most common reasons for non-coverage:

• Medicare doesn’t pay for this test for your condition
• Medicare doesn’t pay for this test as often as this (denied as too frequent)
• Medicare doesn’t pay for experimental or research use tests

For Medicare to consider your ABN valid, you must add at least one reason for each item or service that you list in field “D.” If you leave this field blank, your ABN is likely to be considered null and void, and your patient will not be responsible for the charge.

Make a Good Faith Effort to Estimate Cost in Field “F”

Your practice is required to complete field “F,” which requests an estimated cost for the service you expect Medicare to deny. Even if you don’t have the exact amount, you’ll need to make a good faith effort to determine how much the item or service will cost. This allows the patient to make an informed decision about whether they want to move forward with receiving the service from your practice.

CMS knows you may not be able to enter the exact amount of the service down to the penny, but the agency does ask that you try to make an estimate that’s within $100 or 25 percent of the actual costs, whichever is higher. If your ABN covers more than one item or service, CMS allows you to group the costs together into one estimate.

Remember to Keep ABN to One Page

While most practices simply download the ABN form from the CMS website, others may recreate it using their own word processing software, such as to translate it into other languages, print it larger, or for other reasons. However, you should keep in mind that the ABN form is required to be printed on one page, either legal or letter sized, with space available on the form for you to actually complete all the fields. In other words, you can’t condense it down so tightly that there’s no room to fill out the required blanks.

CMS prefers that you use 12 point font when typing responses into the field, although the agency will allow 10 point font when you’re trying to fit a lot of details into the space.

Resource: For more information about the ABN form, visit the CMS website at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/abn-form-instructions.pdf.

Torrey Kim, Contributing Writer, Raleigh, N.C.