Revised ABN Form Released by CMS

09 Apr 2017

CMS has released an updated version of the Advanced Beneficiary Form (ABN) form which includes a newly incorporated expiration date on the form as well as language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed.  The effective date for use of the new ABN form is 6/21/2017.  A copy of the new form in both English and Spanish as well as instructions for completing the ABN can be downloaded here.

The roll-out of the new form gives us an opportunity to review the appropriate utilization of ABNs.  I still encounter therapists who are unaware or unsure of when to issue an ABN and, as a result, use them inappropriately.  First, therapists are required to issue an ABN to Medicare beneficiaries prior to providing therapy services that are “not medically reasonable and necessary regardless of the therapy cap”.  The ABN informs the patient why Medicare may not or will not pay for a specific item or service and allows the patient to choose whether or not to receive the item or service and accept financial responsibility.  Issuance of an ABN allows the provider to charge the beneficiary if Medicare doesn’t pay.  If the ABN isn’t issued when it is required and Medicare doesn’t pay the claim, the provider will be liable for the charges.

A voluntary ABN may be provided as a courtesy to the Medicare beneficiary when the therapist provides a service that Medicare never covers, such as a service that fails to meet the definition of a Medicare benefit or a service that is explicitly indicated as a non-covered service.  Medicare has stated that there is no requirement for providers to alert beneficiaries to financial liability prior to providing a service that is never covered. Providers may, however, issue an ABN as an optional notice to alert the beneficiary to liability.

Keep in mind that if the therapist is appending a KX modifier to services provided above the Medicare therapy cap, he/she is informing Medicare that the patient qualifies for an exception and that he/she expects services to be reimbursed due to the skilled nature of those services and the need for continued care.  In those instances, an ABN would not be needed as the KX and the ABN would contradict each other.  It is very important not to issue “blanket” ABNs, i.e. do not have all patients who have met the cap or the $3,700 threshold sign an ABN just to cover yourself in the event that Medicare doesn’t pay for the services.  It is up to the clinician to determine whether or not additional care is medically necessary and to document accordingly to support that need.  Furthermore, the decision to continue therapy should not hinge on where the patient is in regard to his or her therapy cap.  Continuation of care should be based on the necessity of skilled therapy services in order for the patient to progress toward his or her long term goals.  If the therapist feels that additional care is not warranted or cannot be justified in the documentation, then the patient should be discharged to a home exercise program, progressed to an after-care program, or referred back to his or her physician.  If the patient wants to receive care (at ANY point, not just above the cap or threshold) and the therapist does not feel he/she can justify medical necessity for continued skilled intervention, then the patient should be offered an ABN including an explanation of why additional care will, most likely, not be covered.  The financial responsibility would then shift to the patient if he or she signed the ABN.

It is important to make sure your staff (and your patients) understand when and how ABNs are to be used.  If you have any questions, please don’t hesitate to contact us or leave a comment below.