Do You Have a Ticking ABN Bomb?
October 14th, 2009 - Timothy W. Boden, CMPE If you’re an experienced medical biller or coder, you already know that CMS requires providers to inform Medicare patients when the procedures, tests or treatments they recommend may be denied by Medicare, and secure the patient’s signature on a completed Advanced Beneficiary Notice of Noncoverage (ABN) before the procedure or treatment.
Unfortunately, a very large number of physicians, non-physician providers, nurses and other clinical staff don’t even know what an ABN is. And an alarming number of practices believe they are in compliance because they have patients sign a blank ABN (“just in case”) during check-in.
Using ABNs properly while maintaining efficiency in the office presents a significant challenge—and it can be done—but not without the physicians’ and clinical staff’s full cooperation.
Preparation
- Make sure you have the revised form on hand. The footer will identify it as: “Form CMS-R-131.(03/08).” You can download the revised form directly from the CMS Website. If you don’t feel like working your way through the confusing layers of the site’s menus, you can simply type http://www.cms.hhs.gov/BNI/Downloads/ABNFormInstructions.zip in your browser’s address bar to download the form, its instructions and a Spanish translation.
- Make the form easily available to everyone in the practice who might use it.
- Create a simple “cheat sheet” for filling out the form, including examples of properly completed forms.
- Revise your encounter form to include the modifiers GA, GZ and GY* for providers to circle when appropriate.
Training
- Meet with the physicians to ensure they understand the form and its requirements. Let them know it is simply illegal to bill Medicare patients for non-covered services if you haven’t obtained their informed consent. Provide them a list of your practice’s common services requiring ABNs.
- Train nurses how to talk to patients regarding non-covered services, how to complete the form and acquire the patients’ signatures. Provide them the same list of common services requiring ABNs.
- Train front-desk personnel and appointment clerks regarding Medicare non-covered services common for your office. For example, if a Medicare beneficiary wants to schedule an annual physical, the appointment clerk should tell him or her, “You may already know that Medicare doesn’t pay for that, so you will be required to pay the entire amount.” If the patient still wants the exam, train check-in clerks how to present the form and secure a signature.
- Explain to everyone how to handle the occasional patient who refuses to sign an ABN but still wants the procedure in question: Document the patient’s refusal in the chart, and have the provider and a witness sign the ABN.
Implementation
- Identify and train several “experts” who thoroughly understand ABN policies and procedures. They can serve as extra resource people when staffers have questions during busy clinic hours.
- It makes the most sense for nurses and medical assistants to be responsible for the majority of ABNs processed in the clinic, to assure that the documents are in the charts and that the appropriate modifiers are marked on the encounter forms.
This process is not to be taken lightly. The OIG has specially targeted ABNs in its annual work plan before, and you can expect it again—especially now that the form and procedures have been revised and refined. Failure to comply with ABN rules could cost you in lost reimbursement and fines and penalties.
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*GA—indicates you expect the claim to be denied as not reasonable and necessary, and you have a proper ABN on file; GZ—indicates the same except you do not have a proper ABN on file. GY—indicates the service is statutorily excluded or does not meet the definition of any Medicare benefit (an ABN is not required).
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