coding q & a
The Ins and Outs of an ABN
An Advance Beneficiary Notice lets the patient pay when Medicare won't.

By Suzanne Corcoran, C.O.E.

Medicare just published new rules governing when and how to get an Advance Beneficiary Notice (ABN). Here's what you need to know.

When should I use an ABN?
Answer: You must use the official Center for Medicare and Medicaid Services (CMS) form (CMS-R-131-G). Use the same form for professional services and post-cataract eyeglasses. Medicare requires an ABN for both assigned and non-assigned claims, as well as for dispensaries that don't have Medicare supplier numbers. Use it for Medicare patients only. Also use the ABN for your Medi/Medi patients.

Get an ABN whenever you believe that Medicare is likely to deny the claim for an item or service you're planning to provide. Submit your claim with modifier GA added to the appropriate CPT or HCPCS codes.

By signing an ABN, the Medicare beneficiary acknowledges that you advised him that Medicare is unlikely to pay and he agrees to assume responsibility for payment.

You don't need an ABN for services that are statutorily (by law) non-covered by Medicare. In an eyecare practice, this includes refractions and prescribing more than one pair of eyeglasses or contact lenses for pseudophakic patients after each cataract surgery.

What if I don't get a signed ABN?
Answer: A Medicare beneficiary has no responsibility to pay you if he didn't sign an ABN and Medicare denies a claim. You must refund any money you collected unless you successfully appeal the denial. Strict time limits exist for making refunds.

You're not obligated to provide items or services to a Medicare beneficiary who refuses to sign an ABN (other than in an emergency).

May I modify the ABN form?
Answer: You may modify the ABN under these conditions:

• You add your name, address and telephone number at the top. You may also add your logo if you wish to do so.
• The "Items or Services" and the "Because" boxes are for your use. You may preprint lists of items and services and reasons.

You may not alter any other portion of the form. The form must be on one single-side page.

How do I complete the ABN form?
Answer: Fill in the patient's name and Medicare number at the top of the form.

Complete the "Items or Services" box with a description of the professional services or optical features. The description must be complete and easy to understand.

Complete the "Because" box with the reason(s) why you think Medicare will deny your claim. The reason(s) must be clear and comprehensible for the patient. General statements such as "medically unnecessary" aren't acceptable.

Other important points are:

• Get the ABN signed before providing items or services.
• The patient must personally choose Option 1 or Option 2.
• You must have the ABN signed and dated to be valid.
• The "Estimated Cost Field" is optional.

Give the patient a legible copy of the completed and signed ABN. Keep the original for yourself. Both the copy and original should be in blue or black ink on white paper. A photocopy is fine.

Must I always file a claim?
Answer: Yes. Effective October 1, 2002, HIPAA requires a claim any time you get an ABN. If Medicare pays and you have an ABN, refund Medicare.

SUZANNE CORCORAN IS VICE PRESIDENT OF CORCORAN CONSULTING GROUP. REACH HER AT (800) 399-6565 OR AT SCORCORAN@CORCORANCCG.COM.