Are You Correctly Using ABNs?

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Excerpt

Wound care professionals often make the mistake of not offering a service, procedure, or product to a patient when it is not covered by his/her insurance. Some wound care patients have been waiting a long time for their wounds to heal, which means they have also been paying coinsurance for a long time. If a service, procedure, or product is available that may possibly reverse this situation, wound care professionals should educate patients about their options and let them decide what they can afford. Clinicians should not assume a patient will not want the service, procedure, or product.
If the patients have traditional Medicare Part A and Part B insurance, the Centers for Medicare & Medicaid Services (CMS) uses the Fee-for-Service Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, to inform Original Medicare beneficiaries when Medicare may deny payment for an item or service. For the ABN to be valid, providers must use the ABN form currently approved by the Office of Management and Budget (OMB). The ABN form was recently reviewed by the OMB, who made 3 changes to the form:
The “correct” ABN form is available at: www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.
Because wound care professionals continue to ask many questions about how to correctly use the Medicare ABN, let’s review the most common questions that this author receives.
Q: What providers should issue the ABN?
A: The ABN must be used by “notifiers” that include the following:
Q: When must a wound care professional offer an ABN to a Medicare beneficiary?
A: Give a Medicare beneficiary an ABN for a service, procedure, or product that Medicare normally covers, but the notifier believe Medicare will deny payment in this beneficiary’s particular situation. For example, a Medicare Part B–covered beneficiary has had a chronic pressure ulcer for several years. The wound care notifier has unsuccessfully tried many procedures and products, for which the patient has already paid a significant amount of coinsurance. The instructions for use of a particular cellular and/or tissue-based product (CTP) for skin wounds states that the CTP may be used on pressure ulcers, but the Medicare Administrative Contractor in that Jurisdiction has a local coverage determination that covers that CTP only for diabetic and venous ulcers. Nevertheless, the notifier believes the CTP may work for this patient’s pressure ulcer. Therefore, the notifier carefully describes the CTP to the patient and explains that it will probably not be covered by Medicare, but he will be glad to apply it to the patient’s pressure ulcer. The notifier then carefully reviews the ABN with the patient.
Q: How can notifiers determine whether they are using the “correct” ABN form?
A: For the ABN to be valid, notifiers must use the ABN form currently approved by the OMB. The ABN form was recently reviewed by the OMB and has the following words in the lower left corner: (Exp. 03/2020). All notifiers should verify that they have converted to the most recent ABN form. The one dated 03/11 in the lower left corner is not valid after June 20, 2017.
Q: Can notifiers fill in parts of the ABN in advance?
A: Yes, notifiers can fill in the name and contact information for the practice in section A, the item or service covered by the ABN in section D, and the estimated cost in section F.
Note: If the contact information for the notifier’s billing office is different from the practice information in section A, provide the billing office’s contact information in section H.
Q: If the notifier personally explains to the patient the reason he/she believes Medicare will not cover the service, procedure, product, is it necessary to write that reason on the ABN?
A: Yes.
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