CMS instructs mandatory use by September 1

by William L. Malm, ND, RN

In a much anticipated move, CMS released the new Advance Beneficiary Notice (ABN) of Noncoverage March 3. This form, also known as the CMS-R-131, will be used for all Part B provider and supplier services.

The form replaces the existing ABN-G and ABN-L, and it may also be used for voluntary notifications in place of the Notice of Exclusion from Medicare Benefits. It will not replace the SNF ABN (SNFABN-G) form, which is currently under development. (You can view the new ABN form on p. 7 of the PDF of this issue.)

Key points of the new ABN

According to CMS, key features of the form include:

A new official title. The form is now titled “ABN” to more clearly convey the purpose of the notice.

A mandatory field. Indicating cost estimates of the items/services at issue is now mandatory.

A new beneficiary option. An individual may choose to receive an item or service and pay for it out of pocket rather than have a claim submitted to Medicare.

CMS stated that the form is now available for use and will be mandatory beginning September 1. At presstime, CMS had only released the version in English. However, providers can find translation assistance in the “Additional Information” section of the ABN.

Operational effect at your facility

Generally speaking, the processes that you may already have in place for delivering the ABN will suffice. However, it’s important to note some key changes to the form, such as the requirement to provide a reasonable cost estimate. ABNs must still be provided in advance of the item or service being supplied so beneficiaries can “consider the options and make an informed choice.”

CMS also stated that “ABNs are never required in emergency or urgent care situations.”

The presenter must still review the ABN, and all questions must be answered in full prior to the patient’s signature. The beneficiary now chooses from three payment options instead of two:

Option 1 states that the beneficiary wants Medicare to review the case and make a determination. This will require the use of condition codes on the UB-04, specifically condition code 20 in field locators 18–28. This notifies Medicare of the beneficiary’s request for a determination. This code will suspend the claim until a medical review has taken place.

Option 2 states that the beneficiary wants the item or service but requests that Medicare won’t be billed. Therefore, the beneficiary may be asked to pay but cannot appeal to Medicare.

Option 3 states that the beneficiary does not want the item or service and understands that he or she is giving up the option to have it billed to Medicare. Therefore, no determination from Medicare can be made.

The following departments and job functions are specifically affected:

Patient access staff members will need to be retrained on the specific requirements of the new form. If CPT codes are not provided by the ordering physician, patient access may have to look up the procedure in the chargemaster and ensure that the correct item or service is listed under “Items and Services.” This can present compliance risks and may require additional work with the medical staff to ensure that as much information is provided as possible at the time of order.

Finally, patient access will require a robust system for contacting the physician when there is a need for clarification of any test or service in order to arrive at the most accurate CPT in the chargemaster.

The provision of the patient charge for the item or service can be a new operational challenge for the facility. Generally, this will be generated electronically using the pricing within the chargemaster. Therefore, this puts a new burden on the chargemaster coordinator or revenue cycle team to maintain the chargemaster.

Reimbursement officers and CEOs will need to ensure that pricing is consistent with the facility’s policies and procedures for charge determination and that transparency requirements are met.

Information services should adapt the new form for use within the organization. Blank A, or the notifier space, may need to be programmed into the information system to verify that the proper organization name, address, and other required identifying criteria are automatically provided on the form. Additionally, any software used to “scrub” for medical necessity will need to be updated to ensure that it’s compliant with the new form by August 31.

The fine print

CMS states that it will provide a few versions of the new form: a generic ABN and alternative versions with certain blanks completed for “those not wishing to do additional customization as permitted” (including laboratory illustrations). If customization is performed, you must print it on one page—either letter- or legal-size paper.

There are 10 blanks that you must complete, each of which has a corresponding alphabetical label on the form. CMS recommends that if the notifier customizes the form, the labels should be removed. (See the table in this month’s Training Tool for a step-by-step explanation of each of the 10 blanks.)

CMS reiterates that the new ABN is approved by the Office of Management and Budget and may not be altered except as stated in the instructions for implementation.

The overall process and notifier(s) responsibilities haven’t changed. The ABN must be given to beneficiaries in the Original Medicare Program to convey that Medicare is not likely to provide coverage in the specific case. It must be provided in advance of the item, test, or service.

“Notifiers include physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Part B, as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A,” according to the instructions.

The revisions are part of an ongoing process to subject the form to comment and reapproval every three years. CMS will issue the new detailed instructions on the use of the ABN in the online Medicare Claims Processing Manual, Publication 100-04, Chapter 30, prior to the implementation deadline.

In closing

ABNs will continue to play a large role in ensuring that beneficiaries make informed choices regarding the financial liabilities associated with their healthcare. It’s more important than ever for each provider, supplier, and/or facility to have formalized ABN policies consistent with Medicare guidance. Chargemasters must be maintained if used for determining the estimated patient cost. Patient access staff members will need to be retrained on the completion of each field and, specifically, the provision of a cost estimate to the beneficiary.

Revenue cycle committees should take the next several months to include all departments (i.e., patient access, information systems, nursing, chargemaster, and patient financial services) in a comprehensive review of your current processes and make any necessary adaptations required to be consistent with the guidance.

To obtain the most recent information regarding ABNs and to view the new forms, visit the CMS Web site at www.cms.hhs.gov/BNI/02_ABNGABNL.asp.

Editor’s note: Malm is the practice director for revenue cycle management at HCPro, Inc., in Marblehead, MA.