Insurance

06/12/2017

New ABN Form Mandatory June 21st!

CMS has released an updated Advanced Beneficiary Notice of Non-coverage (ABN) form (Form CMS-R-131).  There are no substantive changes to the form or its usage.  However, the updated form has added language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.  The new form also includes the updated expiration date of the form which is 03/2020. 

YOU MUST USE THIS NEW ABN FORM BEGINNING JUNE 21^ST, 2017!!!

The new ABN can be downloaded here: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

The ABN form instructions may be found here: ABN Form Instructions .

A few FAQs about this change and about ABN’s in general:

1. Do I have to get patients currently under care to sign a new ABN form after June 21, 2017?

It is my recommendation that all providers give patients the new ABN for services provided on or after 6/21/17 for covered services that the provider feels Medicare may not pay due to the service not being medically necessary.  According to the CMS Medicare Claims Processing Manual, Chapter 30: Financial Liability Protection, the timing of the ABN notice should be prior to delivery of the item or service in question and provide enough time for the beneficiary to make an informed decision on whether or not to receive the service or item in question and accept potential financial liability.

CMS also states that you must use the most current version of the ABN. Here is what CMS states about the effective version of the ABN:  ABNs are effective as of the OMB approval date given at the bottom of each notice. The routine approval is for 3-year use. Notifiers (providers) are expected to exclusively use the current version of the ABN. Providers/suppliers must be attentive to the OMB approval date on the notice and seek instruction from the CMS website http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html on obtaining current versions of notices. CMS will allow a transition period for providers and suppliers to switch from using expiring notices to newly approved notices. The date of mandatory use of newly approved notices will be announced on the CMS website with the notice’s release. 

2. When do I need to get an ABN form signed by a patient?

Notifiers (providers) are required to issue ABNs when an item or service is expected to be denied.  This may occur at any one of three points during a course of treatment which are: initiation, reduction, and termination, also known as “triggering events”.

A. Initiations: An initiation is the beginning of a new patient encounter, start of a plan of care, or beginning of treatment. If a provider believes that certain otherwise covered items or services will be non-covered (e.g. not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care.

Example: Mrs. S. asks her chiropractor for spinal adjustment treatment because she heard chiropractic care makes one feel better. However, Mrs. S. has no diagnosis that warrants medical necessity of chiropractic treatment but insists on having an adjustment even if she has to pay out of pocket for it. The chiropractic physician’s office personnel issue an ABN to Mrs. S. before the CMT is done.

B. Reductions A reduction occurs when there is a decrease in a component of care (i.e. frequency, duration, etc.). The ABN is not issued every time an item or service is reduced.  But, if a reduction occurs and the beneficiary wants to receive care that is no longer considered medically reasonable and necessary, the ABN must be issued prior to delivery of this non-covered care.

Example: Mr. T is receiving chiropractic care three (3) days a week, and after meeting several goals, therapy is reduced to one (1) day per week. Mr. T wants to achieve a higher level of proficiency in performing goal related activities and wants to continue with treatments 3 days a week. He is willing to take financial responsibility for the costs of the 2 days of chiropractic treatment per week that are no longer medically reasonable and necessary. An ABN would be issued prior to providing the additional days of therapy weekly.

C. Terminations: A termination is the discontinuation of certain items or services. The ABN is only issued at termination if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary.

Example: Ms. X has been receiving covered Chiropractic spinal manipulation services, has met her treatment goals, and has been given spinal exercises to do at home that do not require chiropractic intervention. Ms. X wants her chiropractor to continue to work with her even though continued manipulation is not medically reasonable or necessary. Ms. X is issued an ABN prior to her chiropractor resuming therapy that is no longer considered medically reasonable and necessary. This is classic maintenance care. 

3) How often do I need to have a patient renew their ABN after initially signing one?

A) An ABN can remain effective for up to one year.

Notifiers (providers) may give a beneficiary a single ABN describing an extended or repetitive course of non-covered treatment provided that the ABN lists the services that the provider believes Medicare will not cover. For chiropractic, this would be the 98940, 98941 or 98942 codes.

If applicable, the ABN must also specify the duration of the period of treatment. For example, if you transitioned the patient to maintenance care on 6/1/17 and plan to continue maintenance care until the end of the year; this should be included on the ABN form.

B) If there is any change in care from what is described on the ABN within the 1- year period, a new ABN must be given.

Example: During the initial 30 days of care, the patient exceeded the 12 visit parameter due to the severity of the condition. Provider appropriately had the patient sign an ABN for the visits exceeding the 12 visits during the 30 days. After another 2 months of care, the patient wanted to continue with maintenance care. Another ABN would be signed because the reason changed from the original ABN (frequency of visits vs. maintenance care).

There is a one year limit for using a single ABN for an extended course of treatment.

A new ABN is required when the specified treatment extends beyond one year.

4) If a patient chooses Option 2, advising they do not want Medicare to be billed for services rendered, can I really, legally NOT bill Medicare for the services rendered to a Medicare patient?

Yes, this is permissible because you are following the patient’s directive.

This option allows the beneficiary to receive the non-covered items and/or services and pay for them out of pocket. No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option.

5) Do I need an ABN for services performed that Medicare does not cover when performed by a chiropractor? (therapies, modalities, etc?)

No. ABNs are not required for care that is statutorily excluded from coverage under Medicare. The voluntary ABN serves as a courtesy to the beneficiary in forewarning him/her of impending financial obligation. 

6) Should I have a patient sign an ABN for the non-covered services anyway? Why?

As previously stated, if the services are statutorily excluded then the use of the ABN is strictly voluntary. This would be an individual practice policy decision. However, the use of the voluntary ABN does provide some advantages. First, it provides transparency and fully discloses to the patient their financial obligation. Secondly, it does document that the conversation took place and may be a good resource for the doctor/patient relationship.

7) Are ABN’s needed for patients under a Medicare Advantage Plan?

No. The ABN is an Office of Management and Budget (OMB)-approved written notice issued by providers and suppliers for items and services provided under Medicare Part B, including hospital outpatient services, and certain care provided under Part A (hospice and religious non-medical healthcare institutes only).

The ABN is given to beneficiaries enrolled in the Medicare Fee-For-Service (FFS) program. It is not used for items or services provided under the Medicare Advantage (MA) Program or for prescription drugs provided under the Medicare Prescription Drug Program (Part D).

However, since most Medicare Advantage plans are allowed to establish their own documentation and billing guidelines, it would be prudent to be current with each plan’s regulations and requirements, especially if you are a participating provider with that Part C plan.

For a printable version of these FAQs click here. 

Questions?
Questions regarding the ABN can be emailed to RevisedABN_ODF@cms.hhs.gov