The ABN Made Simple: A Step-by-Step Guide

Medicare ABN Form

The ABN might be a single-page form, but that doesn’t mean it’s a breeze to complete. Filling out an ABN compliantly is a matter of carefully following CMS’ directions for each section of the form. What’s expected isn’t entirely intuitive for practices or for patients, so it’s good to have clarifying advice.

The Top Portion: (Blanks A-C):

In Medicare terms, you as a supplier are the “notifier,” and must include your name, address, and contact information in the small space at the top of the form, although this isn’t spelled out.

The patient’s name must exactly match what’s on the patient’s Medicare card.

The identification number is optional (although the form doesn’t indicate this), and it’s NOT the patient’s Medicare number (HICN on the old cards or MBI on the new cards, which not everyone has received) or Social Security number. CMS says you can use this space to record an internal filing number, such as a medical record number.

The Rest of the ABN Form: (Blanks D-J):

You’ll specify what won’t be covered in column D, using codes and descriptors per item. For instance, if you’re upselling progressive lenses, than you’d add HCPCS code V2781 [Progressive lens, per lens] here. Ensure you give descriptors, and not just the codes, for each non-covered item, since the patient will have no idea what a particular code means, says Tracy Holt, MHR, COPC, transformational services account manager for Eye Care Leaders. The idea here is to inform the patient fully, so it’s best not to lapse into “code-speak.”

In column E, CMS makes it easy for you. You explain “in beneficiary-friendly language,” why the indicated products/services may not be covered. For optical, you could write, “Medicare does not cover photochromic lens coating for glasses after cataract surgery.” You have to give a reason for each item listed in column D, but it can be the same reason if that’s what makes sense.

For column F, you can make a “good faith effort” to provide a cost estimate, says CMS. The goal is to fully disclose to the patient what they’ll have to pay, says Holt. So, if a patient is getting non-covered coatings, you’ll add in those costs, using your usual customary amount. “Most of the time, patients are only going to do what Medicare pays for,” she adds.

Tip:  You won’t need to list the refraction on the ABN since refractions are never covered. But you’ll still want to go over this in advance so the patient is not surprised she is being charged.

Know Your Options

Blank G (Options) is where the patient takes the reins and makes a decision about what you’ve outlined. You cannot decide for the patient, CMS insists. The patient is the one who’s supposed to fill this section out, not the office staff, confirms Holt, but the reality is that it’s the office staff who are doing it in a lot of cases.

A full understanding of each of these three options—and your responsibility—is vital so that you can answer questions knowledgeably and act compliantly.

Option 1

The beneficiary agrees to the non-covered service and pays for it. You file a claim to Medicare, and if Medicare doesn’t pay, the beneficiary can appeal the denial. 

  • Advice: A best practice for this option is to be sure to collect the payment on the date of service and not after the fact, recommends Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, CENTC, CPEDC, CGSC, vice president of strategic development for Eye Care Leaders.

Option 2

The beneficiary receives the non-covered items and pays out of pocket. You don’t file a claim and Medicare isn’t billed. The beneficiary has no appeal rights.

  • Advice: For the optical items that are statutorily denied, you should notify the beneficiary and have them sign and pay up front before the service is rendered, says Buckholtz. “This happens a lot with premium lenses, for example.”

    Option 3

    The beneficiary rejects items and will receive no additional items. There are no appeal rights. 

  • Advice: If you’ve done your prep work well, your patients won’t choose this one. This typically isn’t an option that you would see patients choose in optical, notes Buckholtz.

In section H, the intent is for you, the notifier, to add any clarifying information for the beneficiary. For example, insurance information or “other annotations” you may want to include.

Signed, Sealed, and Almost Delivered:

While it may seem obvious, it’s worth reinforcing that the signature at the end of the form is all-important as an indication that the beneficiary has received and understood the ABN. It also completes the form as an executable document. “We never have patients sign the ABN until they actually decided to have the glasses done,” says Holt.

Collect on the Spot?

You should. And you can work it so that it’s helpful to the patient—and protects your practice’s interests. “We would generally not fill any order without at least half down, whatever the patient responsibility was, and then we would not release the glasses until they were paid in full,” Holt shares.

Streamline Your ABN Process

Starting from scratch with a new ABN for each patient who’s getting add-ons can be tedious and time-consuming. Given that many patients want the same added features when they’re getting post-cataract surgery eyewear, you can save yourself ABN grief by implementing this tip from Buckholtz:

Prepare your ABN forms so they’re prepopulated as much as possible for each procedure/item that would usually be non-covered. “For each service that has an LCD (local coverage determination), you can prepopulate to save time,” says Buckholtz. Then, keep these in color-coded folders so your staff can pull the one they need at the time, rather than filling out a new form from scratch each time.

Photo by Nathan Dumlao on Unsplash

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