ABN's - Ever hear of them??

When speaking to physician groups, I often poll the audience on certain topics. I usually ask them if they are using Advance Beneficiary Notices in their practices and most of the time the replies are an abundance of puzzled looks and questions. Approximately 50% and sometimes as much as 75% of physicians inform me they do not use and/or they have never heard of ABN’s

I share this with you because it is a startling revelation every time it occurs. Failure to use ABN’s can have a significant negative impact on a practice for two reasons. As a former target of the Office of Inspector General, ABN’s were under scrutiny to ensure they were indeed used and if so, used appropriately. Once an OIG target, always a target. The implication is simple; ABN’s can still be audited. Also, failure to obtain an ABN can result in non-payment for the service or procedure by Medicare and the patient, resulting in lost revenue for the practice.

If your practice provides services to Medicare patients and does not use Advance Beneficiary Notices, steps need to be taken to become compliant. If your practice is using the form, it is important to become updated on the changes CMS recently implemented.

Any time a practice provides a service or procedure that it knows Medicare will not cover, or suspects Medicare will not cover for a specific reason, a signed ABN must be obtained from the patient. Essentially the practice is conveying to the patient, through the use of this notice, that Medicare may not reimburse the practice and the patient, by signing, agrees to be financially liable.

Examples of such services would include annual or routine physicals because Medicare does not cover physicals (with the exception of the Initial Preventive Physical Exam), preventive services such as pap smears, hemoccults and mammograms which are assigned time frequency guidelines and cosmetic surgeries. ABN’s are not required in emergency situations.

A new form must be obtained for each visit, when applicable. The practice may not have the patient sign a blank form and use it on an ongoing basis. Additionally, the form must be verbally reviewed with the patient prior to obtaining the signature and providing the service. Original ABN’s should be stored in the patient’s chart.

Effective March 3, 2008, CMS introduced a revised ABN form (CMS-R-131) to replace the prior forms for general use (CMS-R-131-G) and lab services (CMS-R-131-L). A six-month transition period is in place, making it mandatory by September 1, 2008.

The new form is entitled, “Advance Beneficiary Notice of Noncoverage (ABN)” and it contains a mandatory field for providing beneficiaries with cost estimates of the service at issue. A third option is provided to beneficiaries if they want to choose to receive a service and pay for it out-of-pocket rather than have a claim submitted to Medicare.

As with the older versions, CMS is providing the form in English as well as Spanish and allowing practices to download and customize it within certain limitations, including reproducing on a single page only.

When filing claims, the new modifier rules introduced in September 2007 still apply. Whenever a provider obtains an ABN because they expect Medicare will deny the service, Modifier GA must be on the claim form adjacent to the CPT code. Whenever a provider does not obtain an ABN because they expect Medicare will deny the service, Modifier GZ is to be used. All claims not meeting medical necessity of a local coverage determination must also append either Modifier GA or GZ.

It is important, both for patient satisfaction and the bottom line, to get this right. Mistakes can be costly because appeals to correct mistakes must be approved by the patients. Staff education is the first step. The nurse is the logical person to explain the ABN to the patient and obtain the signature. Again, this should be done before the physician/provider sees the patient. Keeping the physician out of financial matters helps to protect the physician/patient relationship.

A key tool to ensure accurate billing is to revise your encounter form to include a space to write in Modifier GA and/or GZ next to the CPT codes whenever applicable. The back office must communicate to the front office what has transpired in order for the data to be entered properly.

When I question physician audiences about ABN usage in the future, I sure hope to receive a lot of enthusiastic “yes” responses.