Neurology & Pain Management Coding Alert

Question: How do I know whether I’m using the correct advanced beneficiary notice (ABN) form for patients?

New Mexico Subscriber

Answer: The correct form for use on and after Jan. 1, 2021, reads “Form CMS-R-131 (Exp. 06/30/2023).” The Centers for Medicare & Medicaid Services (CMS) now offers additional guidelines for patients who are covered by both Medicare and Medicaid, which are known as dual eligible beneficiaries. These patients cannot be charged for Medicare cost-sharing when they receive services under Medicare Part A or Part B.

CMS updated the ABN form and guidelines to solidify the fact that providers cannot bill dual eligible beneficiaries when the ABN is furnished.

“Dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication,” the new ABN guidelines state. “Strike through Option Box 1 as provided below:”

• OPTION 1. I want the (D) listed above. 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.

CMS is specific in its wording. “Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual eligible beneficiaries,” CMS says in the ABN instructions. “If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination.”

Don’t forget that you must provide the patient with a copy of the signed ABN, and you should keep the original ABN on file.

Resource: To access the new ABN form and the latest instructions, visit https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.