ED Coding and Reimbursement Alert

Check out these rules for use as you prepare for the transition.

The Centers for Medicare and Medicaid Services (CMS) Advanced Beneficiary Notice (ABN) forms are not common in the ED setting because of the Emergency Medical Treatment and Active Labor Act (EMTALA). ABNs are never used in emergency situations, however if your group has expanded into non emergent service lines such as office type urgent care an awareness of the ABN rules and requirements may be important.

The ABN form, CMS-131-R, has not really changed except to add closing language that informs patients CMS doesn’t discriminate in its programs and activities and offers a web site and phone number for beneficiaries to request the ABN in an alternate format such as in large print type or a different language if desired, says Mike Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company in Bedford, MA. Because the ABN form is subject to approval by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (PRA), the notice is subject to public comment and re-approval every three years. During the 2016 PRA submission, the alternative format request language was added and the form reflects a new expiration date in the lower left corner of 03/2020.

List Why the Service is Not Covered and What the Cost to the Patient Will Be

This form should be used for traditional Medicare patients when you know that the services they request will not be covered. The form requires that you state to the patient the specific reason why Medicare will not cover the services, such as it is not covered for the patient’s condition or diagnosis or that the service is not coved for this test for your condition or that Medicare does not pay for the identified service within a given frequency such as a pneumococcal vaccine. The explanation must be easy for the patient to understand and the form present and explained prior to the service actually being provided, Granovsky explains.

The provider, or “Notifier” to use the language on the ABN form, must include a good faith effort to insert a reasonable estimate for all of the non-covered items or services to be provided during the encounter. CMS expects that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. Multiple items or services that are routinely grouped can be bundled into a single cost estimate, Granovsky adds.

CMS offers these examples of acceptable estimate language:

For a service that costs $250:

• Any dollar estimate equal to or greater than $150
• “Between $150-300”
• “No more than $500”

For a service that costs $500:

• Any dollar estimate equal to or greater than $375
• “Between $400-600”
• “No more than $700”

Medicare Advantaged or private payers may have their own ABN forms so you should be aware of any updates from any payer with whom you contract, Granovsky warns.