Below you can find a link to a  sample version (in pdf)  of the new Medicare ABN Form that all offices must use starting January 1, 2012. Please download, review, edit name & address, and have your Medicare patients complete this form starting Monday.

NEW MEDICARE ABN FORM – PDF

What is an ABN Form?

“The ABN is a notice given to Medicare beneficiaries to let them know that Medicare is not likely to provide coverage in a specific case. The patient must complete the ABN as described below before providing the items or services that are the subject of the notice.”

What do we need to do with this form?

First, you must put in your clinic name, address and phone number on the form. This is Medicare’s requirement. Have each Medicare patient review the form, check one of the three options, and sign the form. Keep a copy in the patient’s chart for the most current course of treatment.

Why are exams, xrays and therapies noted on the form?

The ABN can be used for both covered, but not medically necessary services (such as a wellness adjustment billed without the –AT modifier) or for non-covered services. Adding non-covered services, such as therapies or exams, helps Medicare patients better understand what will and won’t be paid.

Why is the “Estimated Cost” line left blank?

Because this will vary depending on what you are doing with the patient, whether the patient has a secondary, supplement, or alternative financial agreement with your office. This will be different for different patients. You can either estimate a “per visit” cost or the total cost for care. (per page 4, Form Instructions, ABN).

Please get rid of your older, blank ABN forms. More Questions? Ask Dave!