Ophthalmology and Optometry Coding Alert

Question: We were told to use a new ABN form but we aren’t sure if we have it or if we need to get it. How will we know which form to use?

Texas Subscriber

Answer: CMS recently debuted an updated advance beneficiary notice (ABN) that providers are required to use as of January 1, 2021. If you aren’t sure whether you’ve got the newest one in your form files, check the bottom left of the document. It should say “Form CMS-R-131 (Exp. 06/30/2023)” if you’re using the correct ABN.

Here’s what’s new: If you’re wondering why a new ABN was necessary, it’s because CMS now offers additional guidelines for dual eligible beneficiaries (those patients who are covered by both Medicare and Medicaid). These patients cannot be charged for Medicare cost-sharing when they are administered services under Part A or Part B.

“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.

“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 new guidelines.

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