Otolaryngology Coding Alert

Check out these changes to CMS' ABN form.

The Centers for Medicare and Medicaid Services (CMS) Advanced Beneficiary Notice (ABN) forms are common in most medical practices. You can escape trouble if you can execute the use of ABNs in proper circumstances, and keep the patient informed about the likely non-payment for a particular service.

What is new? CMS announced an update to the ABN form CMS-131-R in March 2017. The following are the key updates in the new form:

1. The form includes language that informs beneficiaries about the "no discrimination" practices of CMS.
2. The form directs beneficiaries to request an ABN in an alternate format, if needed.

"The form has not really changed, except to add closing language that informs patients CMS doesn't discriminate in its programs and activities, and offers a website and phone number for beneficiaries to request the ABN in an alternate format; such as in large print type or a different language if desired," says Mike Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company in Bedford, Massachusetts.

When can you expect to use the new form? CMS has announced that the new form went into effect on June 21, 2017. That means that for all patient dates of service from June 21 and beyond, you should be using the updated CMS-R-131 form.

Look for new expiration date: Because the ABN form is subject to approval by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (PRA), the notice is subject to public comment and reapproval every three years. During the 2016 PRA submission, the alternative format request language was added and the form reflects a new expiration date in the lower left corner of 03/2020 (Form Approved OMB No. 0938-0566). You can find the new form in Word and PDF formats at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

Explain the service and reason for non-payment to the patient: In the form, you see a column where the provider should mention details of the service. Your provider will explain these details to the patient, and also capture the reason why Medicare may not pay for the service.

Your provider will typically use this form for Medicare patients, and will typically explain the condition, diagnosis, or investigation that Medicare will not cover. "The explanation must be easy for the patient to understand" and the provider should share and explain the form to the patient before providing the service, Granovsky says.

Cost estimates: The provider, or "Notifier," should use appropriate language on the ABN form to explain a reasonable estimate for all of the noncovered items or services. Your provider should be able to give a good faith estimate based upon the frequency and duration of the service. CMS expects that the estimate should be within $100 or 25 percent of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted.

You can bundle multiple items or services that are routinely group together into a single cost estimate, Granovsky says.

Payer preferences: For patients who are not covered by Medicare, you should check for their payer's ABN requirements - if it has any. "Medicare Advantage or private payers may have their own ABN forms, so you should be aware of any updates from any payer with whom you contract," Granovsky warns.