GENERAL

1. What is an ABN?
2. What is the purpose of the ABN?
3. Can ABN's be given on a routine basis?
4. Is an ABN required for statutorily excluded items or services?
5. A physician orders a lab test; the specimen collection is done in the physician office, and is sent to the lab for processing. Is the lab or physician responsible for executing the Advance Beneficiary Notice (ABN)?
6. How do I determine if an ABN is required for a screening, such as mammography or PSA?
7. When would I report modifier GA?
8. When would I report modifier GY?
9. When would I report condition code 20 on an outpatient claim?
10. When would I report condition code 21?
11. What is a demand bill?
12. Where can I find the ABN forms?

1. What is an ABN?

   An ABN is a written notice a provider gives a Medicare beneficiary before items or services are furnished when the provider believes that Medicare probably or certainly will not pay for some or all of the items or services on the basis of medical reasonableness and necessity [Social Security Act §1862(a)(1)] and custodial care [Social Security Act §1862(a)(9)].

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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2. What is the purpose of the ABN?

   The purpose of the ABN is to:

   • Inform a Medicare beneficiary, before he or she receives specified items or services that otherwise might be paid for, that Medicare probably will not pay for them on that particular occasion.
   • Allow the beneficiary to make an informed consumer decision whether or not to receive the items or services for which he or she may have to pay out of pocket or through other insurance.
   • Allow the beneficiary to better participate in his/her own health care treatment decisions by making informed consumer decisions.

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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3. Can ABN's be given on a routine basis?

   Routinely issued ABNs are permitted in the following situations:

   • For items and services never covered, under any circumstances, as not reasonable and necessary under §1862(a)(1) of the Act (e.g., acupuncture).
   • For items and services which Medicare considers to be experimental (e.g., “Research Use Only” and “Investigational Use Only” laboratory tests) and, therefore, not reasonable and necessary under §1862(a)(1) of the Act.
   • Any item or service for which Medicare has established a statutory or regulatory frequency limitation on coverage, or a frequency limitation on coverage on the basis of a national coverage decision or on the basis of Local Coverage Determination (LCD), because all or virtually all beneficiaries may be at risk of having their claims denied in those circumstances. The ABN must state that “Medicare does not pay for this item or service more often than [frequency limit].
   • For DMEPOS that likely will be denied because the supplier has no supplier number or because the supplier made an unsolicited telephone contact (“cold call”), because these denials apply to all varieties of medical equipment and supplies and to all Medicare beneficiaries equally.

   Reference: CMS Pub 100-4, Chapter 30, Section 40.3.6.4

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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4. Is an ABN required for statutorily excluded items or services?

   No. An ABN is not required for statutorily excluded items or services, although providers may voluntarily provide a notice. This notice, called a “Notice of Exclusion of Medicare Benefits” (NEMB).  Beginning September 3, 2008, all providers, must begin using the revised Advance Beneficiary Notice of Noncoverage (ABN).  The revised version of the ABN may also be used to provide voluntary notification of financial liability.  The revised ABN may be found on the CMS website.

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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5. A physician orders a lab test; the specimen collection is done in the physician office, and is sent to the lab for processing. Is the lab or physician responsible for executing the Advance Beneficiary Notice (ABN)?

   Whether the physician or the laboratory collects the specimen, it is still the laboratory's responsibility to execute the ABN because the laboratory has the risk of financial liability in the case of a denial. However, we encourage physicians to execute ABNs in these situations, since the physician has the better opportunity to give notice.

   Reference: CMS Pub 100-04, Chapter 30, Section 50.7.8

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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6. How do I determine if an ABN is required for a screening, such as mammography or PSA?

   You can verify prior screening information on page 6 of Health Insurance Query Access (HIQA).

   For any item or service for which Medicare has established a regulatory frequency limitation on coverage, routinely issued ABNs are permitted. The ABN must state that “Medicare does not pay for this item or service more often than [frequency limit]. For additional details, refer to previous question, “Can ABN’s be given on a routine basis ?”.

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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7. When would I report modifier GA?

   If a service not pertaining to the ABN was rendered in the same period as a service requiring an ABN, such services must be submitted on a separate claim and the statement dates of these claims cannot overlap. If the time periods cannot be separated, a single claim must be submitted, just for the overlapping period, using occurrence code 32 (date ABN given) showing all services as covered and placing modifier GA on the HCPCS code to identify the service line for which the ABN was given.

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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8. When would I report modifier GY?

   Modifier GY is reported when you believe a service will be denied because the service is statutorily excluded or does not meet the definition of any Medicare benefit.

   The GY modifier is submitted as a non-covered line item on a claim with other covered services. GY modifier is used on all line items for statutory exclusions. This option should be used only when providers are unable to split non-covered services onto a separate claim.

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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9. When would I report condition code 20 on an outpatient claim?

   In a situation in which giving an ABN (Form R-131) is not appropriate, and a beneficiary demands a Medicare determination for any line items. Claims with Condition Code 20 may be submitted with both covered and non-covered charges.

   Important Note: For information on reporting condition code 20 on SNF Inpatient claims, please refer to:

   References:

   • Pub-100-4, Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections, Section 70- Form CMS 10055 Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN).
     
     Note: The SNF ABN is still a draft document. You will be notified of it's mandatory use in the near future.
     http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf
     
     
   • Pub 100-4, Chapter 1, Section 60.3 and Pub 100-4, Chapter 6, Section 40.9
     
     
   • When Medical Requirements Are Not Met: (SNF) Demand Billing- FAQs

   Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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10. When would I report condition code 21?

    When a beneficiary wants a denial that can be passed on to subsequent payers. A provider may submit claims, for initial determination, for statutorily excluded services, if the beneficiary requests it. On claims for statutorily excluded services, the provider should enter condition code 21 to indicate that it realizes that the furnished services are excluded, but that it is requesting a denial notice from Medicare in order to bill other insurers. This is also known as a “no pay” claim. NOTE: Condition codes 20 and 21 should never be reported on the same claim as occurrence code 32.  Additionally, when billing for denial, specific remarks need to be present on your claim; as to denial needed

    Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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11. What is a demand bill?

    A demand bill is a complete, processable claim, which must be submitted by the provider upon the request of the beneficiary.

    A demand bill is requested usually, but not necessarily, pursuant to notification of the beneficiary that the provider expects Medicare to deny payment of the claim.

    In a situation in which giving an ABN (Form R-131) is not appropriate, a demand bill can be submitted using condition code 20.

    Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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12. Where can I find the ABN forms?

    The CMS-R-131-G, for General Use and the CMS-R-131-L for Laboratory Tests are located at the CMS web site. Beginning Monday, March 3, 2008, providers (including independent laboratories), physicians, practitioners, and suppliers may use the revised ABN for all situations where Medicare payment is expected to be denied. The revised ABN replaces the existing ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007). CMS will allow a 6-month transition period from the date of implementation for use of the revised form and instructions. Thus, all providers and suppliers must begin using the revised ABN (CMS-R-131) no later than September 1, 2008. http://www.cms.hhs.gov/bni/01_overview.asp

    Date Posted: 02/24/2004, Date Reviewed/Revised: 06/25/2008

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