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Advanced Beneficiary Notices (ABNs) for the Medicare MNT benefit

Dietetics practitioners who are participating in the Medicare program as providers for MNT for diabetes and non-dialysis kidney disease should understand and use appropriate forms, such as the Advanced Beneficiary Notice (ABN), prior to providing MNT services to Medicare beneficiaries with diabetes or non-dialysis kidney disease.

Advanced Beneficiary Notices (ABN) Definition¹
An Advanced Beneficiary Notice (ABN) is a written notice used by Medicare providers and suppliers to notify Medicare beneficiaries, before the service is provided, of the following:

That Medicare will probably deny payment for the service/supply,
The reason why the provider expects Medicare to deny the payment, and
The Medicare beneficiary is personally and fully responsible for payment if Medicare denies payment.

In addition to the above items, the ABN must also describe the service, include the patient's name, billing account, Medicare number, patient's signature, and date, and if needed include space for a witness' signature and date. The intent of ABNs is to empower Medicare beneficiaries to be active participants in their own health care treatment decisions.

A properly executed ABN serves as notice to a Medicare beneficiary, the patient, that the beneficiary is responsible for the payment if Medicare denies payment. ABNs are used with Medicare covered services only and the form should be used when the RD or provider is unsure that a service is will be considered medically necessary or may exceed the frequency and duration of the covered service. If the provider is certain that Medicare does not cover a service, then an ABN is not needed,². If items or services are always non-covered under the Medicare program, (e.g. MNT for other diagnosis besides diabetes and non-dialysis kidney disease), the patient must pay the full bill and advance notice from the provider is not necessary. There is nothing that prevents providers from using ABNs, however in cases where Medicare does not cover the service, the ABN is not needed and the provider can state with certainty that the Medicare beneficiary will have to pay for the services. According to the Medicare Carriers Manual, giving ABNs for all claims or services is not an acceptable practice.

ABN Use — Examples:
Example 1: You receive a referral from an MD to see a Medicare patient for MNT services for diabetes. The patient lives in Florida part of the year, and Arizona part of the year. You see the Medicare beneficiary in your practice in Arizona, and neither you nor the client has access to the patient's medical records in Florida. You review the medical record from the physician in Arizona and your screening is inconclusive as to how many MNT visits for diabetes this person has had in the last 12 months. You should complete the ABN and explain its use with the Medicare beneficiary before seeing the patient for MNT for diabetes.

Example 2: (An ABN may be applied to an extended course of treatment provided the notice identifies each service for which Medicare is likely to deny payment. However, a separate notice is required, if additional services, for which Medicare is likely to deny payment, are furnished later in the course of treatment.) A patient with the diagnosis of diabetes has attended all the Medicare MNT visits allowed in an episode of care. This patient's condition has consistently and progressively improved as evidenced by a change in A1C values from 9.5% to 8.0%. The referring physician's evaluation is that with an addition one to two MNT visits the patient will improve to A1C goal of 7%. The RD receives this referral for an additional two visits. Medicare will probably not cover these visits since the Medicare patient has exceeded the MNT duration and frequency requirements of the benefit. Therefore the RD must tell the patient in advance and in writing, that Medicare will probably not cover the service. The patient receives the ABN from the RD and is requested to sign and date the statement. With this advance notice, the patient knows that he/she will have to pay the provider the entire billed amount should Medicare deny payment.

Sample ABN Copy
The Centers for Medicare & Medicaid Services has created a sample ABN that can be used as a template for RD Medicare providers in private practice or Medicare facilities who require this form. Whether RD Medicare providers use CMS' ABN form or another ABN form created by your facility, remember to use a consistent form that is personalized with the following components:

the RD/facilities' letterhead
description of the service
reason why the service may not be covered
the patient's name, billing account number, Medicare number, signature and date
if needed, space for a witnesses signature and date

CMS' ABN form includes these components and uses large font size for easy readability by the Medicare beneficiary. Access CMS' ABN form from their Web page at: http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp.

Sample Language To Use
A critical point about filling out the ABN that must be observed is that terminology used on the form must describe why Medicare is unlikely to cover the service. CMS does not accept statements like, "I never know if Medicare will deny payment" and similar generalizations for advance notice purposes. Following are a few examples of acceptable statements of reasons RDs believe that Medicare is likely to deny payment for MNT services.

Medicare does not usually pay for this many visits or treatments.
Medicare usually does not pay for like services by more than one dietitian during the same time period.
Medicare usually does not pay for this many services within this period of time.
Medicare usually does not pay for more than one visit a day.
Medicare usually does not pay for like services by more than one dietitian.
Medicare usually does not pay for this service.

Patient Refuses To Sign ABN³
If the ABN is completed and presented it to the patient, and during the discussion about the patient's responsibility to pay for the service if Medicare denies payment, the patient refuses to sign the ABN -- what do you do? What are your options? RDs could refuse to provide the service, or RDs could decide to provide the MNT service even without the signed ABN. In either case you must document the patient's refusal to sign the ABN and have a witness (a co-worker) also sign the ABN. If Medicare payment is denied, the Medicare beneficiary will be responsible for the payment.

Situations Where An ABN May Not Be Required For MNT Services⁴
There are a few cases when an ABN may not be required for MNT services for diabetes and non-dialysis kidney disease since the RD is confident that Medicare will cover the services. These situations may include:

The Medicare beneficiary meets the diagnosis criteria for MNT services for diabetes or non-dialysis kidney disease, a physician referral and chart documentation is provided specifying the medical necessity for MNT for the beneficiary with diabetes or non-dialysis kidney disease, and the individual has never received MNT by an RD.
The Medicare beneficiary meets the diagnosis criteria for MNT services for diabetes or non-dialysis kidney disease, a physician referral and chart documentation is provided specifying the medical necessity for MNT for the beneficiary with diabetes or non-dialysis kidney disease, and the individual has not exceeded the MNT episode of care (the frequency and duration of MNT for diabetes or non-dialysis kidney disease).
The Medicare beneficiary meets the diagnosis criteria for MNT services for diabetes or non-dialysis kidney disease, a physician referral and chart documentation is provided specifying the medical necessity for MNT for the beneficiary with diabetes or non-dialysis kidney disease, and the individual has not exceeded the MNT episode of care (the frequency and duration of MNT for diabetes or non-dialysis kidney disease) and, the Medicare beneficiary is not enrolled in a Medicare Diabetes Self-Management Training (DSMT) program. In this case, the coordination of care between the DSMT program and MNT program, that may potentially limit MNT services, will not apply.

Practice Tips:

RDs should use ABNs with Medicare beneficiaries who are referred by a physician for MNT for diabetes and non-dialysis kidney disease, and there is uncertainty whether Medicare will cover the service.

The ABN form must include all required components and be used consistently with Medicare beneficiaries before the MNT services are provided.

On the ABN form, be specific when listing why Medicare may deny the services. CMS does not accept statements like, "I never know if Medicare will deny payment" and similar generalizations for advance notice purposes.

For all services for which Medicare does not pay at all e.g. MNT is only a Medicare Part B covered benefit for diabetes and non -dialysis kidney disease, beneficiaries and providers including RDs can privately work out payment agreements, without any Medicare involvement. In this case, no ABNs are required. See additional instances where an ABN may not be required for MNT Medicare benefit services.

Practice Management
RDs in private practice must have policies and procedures in place regarding ABNs. As part of the Medicare audit process set up to monitor MNT Medicare practices, RDs should review ABN use/appropriateness. The following ABN checklist can be used to develop ABN polices and procedures.

Good record keeping
o Document receipt of each advance beneficiary notice (ABN) and make a copy for the patient, even though CMS regulations only require copies when requested. It is good practice to give patients a copy so there are fewer surprises when they get the bill.
o File the original copy in the patient's office record.
o When patients refuse to sign an ABN, inform them of the consequences and document the conversation.

Advance Beneficiary Notices (ABN) must be used if the service:
o Is for investigative or research use only,
o Does not meet medical necessity requirements according to your local medical review policy or CMS National Coverage Limitations,
o May only be paid for a limited number of times within a specified time period and this visit may exceed that limit (Note: ABNs are also required if there is no diagnosis, sign, symptom, or ICD-9-CM code provided, and if one cannot be obtained from the ordering physician.)

Medical necessity
o Review each patient's diagnosis, symptoms, disease(s) or ICD-9-CM code(s) for medical necessity, according to local medical review policy or National Coverage Limitations
o Document the reason for determining that a test or service is not medically necessary.

Obtain any documentation necessary to support your reason in case of an audit.

ABN checklist

Providers should not give notices to beneficiaries unless the provider has some genuine doubt regarding the likelihood of Medicare payment as evidenced by his or her stated reasons; giving notices for all claims or services is not an acceptable practice." The Medicare Carrier Manual, Sec. 7300.4 and 7300.5.

1 CMS Web page;http://www.cms.hhs.gov/medicare/bni/

2 http://www.ioms.org/legislation/update_medicare_January2001.htm

3 42 U.S. C. 1395ppp, Medicare Carriers Manual-7300.5, Blue Cross/Blue Shield of Kansas, Medicare Part B Physician's Manual, pg. 177.Carrier Advisory Committee for Illinois Medicare Part B. Accessed from: http://www.creightom.edu/billingcompliance/babn11.02.doc

4 What Doctors Need to Know About the Advance Beneficiary Notice (ABN), access from CMS Web page 6/04; http://www.cms.hhs.gov/medlearn/abn_readers.pdf

*The information is for reference use only and does not constitute the rendering of legal, financial, or other professional advice of the American Dietetic Association. (12/01)