Blank D; I suggest stating the procedure is being done on both the left and the right sides versus "bilaterally", as the information is required to be easy for the patient to understand:
"Blank D requires providers to list the specific items or services the provider believes will not be covered by Medicare. CMS encourages providers to use one of the following descriptors in Blank D: item, service, laboratory test, test, procedure, care, or equipment. For expected partial denials, the provider is required to list the excess components of item or service for which denial is expected. Similarly, a provider must also list the specific components of any upgrades that may be, are expected to be, or will be denied. If an item or service that is offered — but expected to be denied — is repetitive or continuous, then the provider must specify the frequency or duration of the item or service to be provided on ABN form. When a provider reduces services, Blank D must specify with enough additional information to put the Medicare beneficiary on notice of the nature of the reduction. For example, “wound care supplies decreased from weekly to monthly” is sufficient, but “wound care supplies decreased” is insufficient."
Blank F, Estimated Cost:
"In order for Medicare beneficiaries to receive all information and make an informed decision, Blank F requires providers to disclose to beneficiaries an estimated cost for the item or service Medicare is not likely to cover. In making an estimate, providers must make a good faith effort to determine a reasonable estimate for the items or services listed. Generally, CMS expects the provider’s estimate to fall within the greater of $100 or 25 percent of the actual cost." There's also a notation that states "You can bundle routinely grouped multiple items or services into a single-cost estimate", so you wouldn't have to divide the cost into 2 because the procedure is grouped together due to it being bilateral.
Using 19318 Reduction mammaplasty as an example (I don't know if it's subject to any restrictions, I just randomly picked a code that I knew had a 50) -
The MC fee schedule amt is $1,132.49 (unilaterally)
19318-50 is subject to the multiple procedure reduction, so the FS amt would then be ~$1,698.73 (rounded down)
So, you could not charge more than ~$2,123.41 (125% rounded down)
You'd also have to list any associated lab work, tests, or other services you intend on providing in conjunction with the procedure in each blank if you believe they will also be denied.
There's an interactive ABN form here:
https://www.cms.gov/Outreach-and-Ed.../ABN-Tutorial/formCMSR131tutorial111915f.html
The actual form can be downloaded here:
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
Here's a booklet to reference as well:
https://www.cms.gov/Outreach-and-Ed...NProducts/Downloads/ABN_Booklet_ICN006266.pdf