On July 14, 2021, the CMS' Change Request 12242 announced various revisions and deletions1 to the Advance Beneficiary Notice of Non-Coverage (ABN) section of the Medicare Claims Processing Manual Chapter 30, Section 50. Because these important changes go into effect on October 14, 2021, all wound/ulcer management physicians, qualified healthcare professionals, and revenue cycle team members should read and implement these changes.
Medicare provides the ABN form CMS-R-1312 for healthcare professionals, providers, and suppliers to provide a written notice to Medicare beneficiaries each time, and as soon as, they determine that Medicare payment certainly or probably will not be made. The written ABN allows the beneficiary to make an informed decision about whether to receive the item and/or service and better participate in his/her own healthcare treatment decisions.
If the ABN standards are followed and the Medicare beneficiary signs the ABN and accepts the service, procedure, or product that Medicare will certainly or probably not cover, the patient accepts the financial liability for the item or service described by the ABN. This author continues to emphasize ABNs to wound/ulcer management professionals, providers, and suppliers because many report that they never use ABNs. CAUTION: Medicare contractors may hold financially liable any healthcare provider or supplier who either failed to give notice when required or gave a defective notice.
The ABN form is reviewed and approved every 3 years by the Office of Management and Budget. The expiration date of the ABN is printed in the bottom left corner of the form. The current ABN's expiration date is June 30, 2023. If you are using an ABN form with an older expiration date, you are out of compliance and should immediately switch to the current version. Further, you should read the step-by-step instructions for completion of the current version.
Now let us review some of the highlights of the October ABN regulation changes.
GENERAL ABN PREPARATION REQUIREMENTS
* The notifier should make a minimum of two copies of each ABN: one for the Medicare beneficiary and the original for the notifier.
* The notifier may reproduce the ABN by using self-carbonizing paper, photocopying, and digitized technology that conforms to all applicable requirements.
* The ABN should not exceed one page (either letter or legal size). However, attachments are permitted for listing additional items and services if the items/services clearly match the reason and cost estimate information.
* The ABN should be reproduced on a pale-colored paper with a visually high-contrast dark ink.
* Notifiers should maintain fonts as they appear in the ABN downloaded from the CMS website.
Title should be in 14- to 16-point font.
All other form words should be in 12-point font.
Information inserted by the notifier may be legibly handwritten or typed in no smaller than 10-point font.
If the type of font needs to be changed, alternative fonts that are easily readable, such as Arial, Arial Narrow, Times New Roman, and Courier, may be used.
* Notifiers may customize the ABN, if the following guidelines are followed:
Notifiers may preprint information in certain blanks to promote efficiency and ensure clarity for the beneficiaries. Lettering of the blanks (A-J) should be removed prior to issuing an ABN. NOTE: Blanks (G) through (I) must be completed by the beneficiary and should not be prefilled.
If preprinted information is used to describe items/services and/or common reasons for noncoverage, the notifier must clearly indicate on the ABN which portions of the preprinted information pertain to the beneficiary.
If the notifiers choose to preprint a menu of items or services, they should list the cost estimate next to each item or service.
Notifiers may develop multiple versions of the ABN to align with common treatment scenarios.
CAUTION: No other modifications may be made to the ABN. In fact, if the ABNs are changed too much, the Medicare contractor or the CMS central or regional office can declare the ABN invalid and not allow the notifier to collect payment from the beneficiary.
REPETITIVE OR CONTINUOUS NONCOVERED CARE
If a beneficiary is going to receive an extended or repetitive course of noncovered treatment, the notifier may give one ABN to the beneficiary. However, the ABN must (1) list all items and services that the notifier believes Medicare will not cover and (2) specify the duration of the treatment period. That ABN will remain effective after valid delivery to the beneficiary if no change has occurred in
* the care described in the original ABN;
* the beneficiary's health status, requiring a change to the treatment for the noncovered condition; and/or
* the Medicare coverage guidelines for the items or services.
If any of the above changes occur during the course of treatment, the notifier must provide the beneficiary with a new ABN. If repetitive or continuous services are still occurring after 1 year, the notifier may issue another ABN to the beneficiary, but this is not required unless any of the changes listed above apply.
OBLIGATION TO BILL MEDICARE
Once a Medicare beneficiary has been issued an ABN, she/he has the right to ask the notifier to submit a claim to Medicare for an official payment decision. To enact that right, the beneficiary must choose Option 1 on the ABN and receive the item/service described in the ABN:
OPTION 1. I want the _________________ listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays, or deductibles.
If the Medicare beneficiary selects Option 1, the professional, provider, or supplier should report the noncovered item/service/procedure code with the GA modifier on the Medicare claim. The GA modifier indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare. In addition, use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability.
NOTE: If the beneficiary selects Option 2 on the ABN, the professional, provider, or supplier is not required to submit a claim to Medicare:
OPTION 2. I want the __________________ listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
DUAL ELIGIBLE INDIVIDUALS WHO HAVE QUALIFIED MEDICARE BENEFICIARY AND/OR MEDICAID COVERAGE
Because professionals, providers, and suppliers cannot bill a dual eligible beneficiary when an ABN is furnished, the beneficiary must be instructed to check Option 1 on the ABN for a claim to be submitted for Medicare. The provider must strike through Option 1 as indicated:
OPTION 1. I want the _________________ listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays, or deductibles.
CAUTION: If you provide care for individuals with this coverage, it is imperative that you read the entire section of the Medicare Claims Processing Manual to properly bill these claims.
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