Do we need to initmate on the claim about ABN notification?

Medicare Part B advance beneficiary notices


Medicare Part B allows coverage for services and items  deemed medically reasonable and necessary for treatment and diagnosis of the patient.

For some services, to ensure that payment is made only for medically necessary services or items, coverage may be limited based on one or more of the following factors (this list is not inclusive):


?? Coverage for a service or item may be allowed only for specific diagnoses/conditions. Always code to the highest level of specificity.

?? Coverage for a service or item may be allowed only when documentation supports the medical need for the service or item.

?? Coverage for a service or item may be allowed only when its frequency is within the accepted standards of medical practice (i.e., a specified number of services in a specified timeframe for which the service may be covered).

If the provider believes that the service or item may not be covered as medically reasonable and necessary, the patient must be given an acceptable advance notice of Medicare’s possible denial of payment if the provider does not want to accept financial responsibility for the service or item. Advance beneficiary notices (ABNs)  advise beneficiaries, before items or services actually are furnished, when Medicare is likely to deny payment.

Patient liability notice

The Centers for Medicare & Medicaid Services’ (CMS) has developed the Advance Beneficiary Notice of Noncoverage (ABN) (Form CMS-R-131), formerly the “Advance Beneficiary Notice.” Section 50 of the Medicare Claims Processing Manual provides instructions regarding the notice that these providers issue to beneficiaries in advance of initiating, reducing, or terminating what they believe to be noncovered items or services. The ABN must meet all of the standards found in Chapter 30. Beginning March 1, 2009, the ABN-G and ABN-L was no longer valid; and notifiers must use the revised Advance Beneficiary Notice of Noncoverage (CMS-R-131). Section 50 of the Medicare Claims Processing Manual is available at http:// www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/ clm104c30. pdf#page=44.

Reproducible copies of Form CMS-R-131 ABNs (in English and Spanish) and other BNI information may be found at http://www.cms.gov/ Medicare/Medicare- General-Information/ BNI/index.html. ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item. Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item. Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

 Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

CMS - 1500 Claim Form Instructions: Revised for Form Version 02/12

Form Version 02/12 will replace the current CMS 1500 claim form, 08/05, effective with claims received on and after April 1, 2014:

·         Medicare will being accepting claims on the revised form, 02/12, on January 6, 2014;

·         Medicare will continue to accept claims on the old form, 08/05, through March 31, 2014;

·         On April 1, 2014, Medicare will accept paper claims on only the revised CMS 1500 claim form, 02/12; and

·         On and after April 1, 2014, Medicare will no longer accept claims on the old CMS 1500 claim form, 08/05.

The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June 10, 2013, the White House Office of Management and Budget (OMB) approved the revised form, 02/12. The revised form has a number of changes. Those most notable for Medicare are new indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify whether certain providers are being identified as having performed an ordering, referring, or supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of numbers, as diagnosis code pointers and expands the number of possible diagnosis codes on a claim to 12.

The qualifiers that are appropriate for identifying an ordering, referring, or supervising role are as follows:

·         DN - Referring Provider

·         DK - Ordering Provider

·         DQ - Supervising Provider

Providers should enter the qualifier to the left of the dotted vertical line on item 17.

The Administrative Simplification Compliance Act (ASCA) requires Medicare claims to be sent electronically unless certain exceptions are met. Those providers meeting these exceptions are permitted to submit their claims to Medicare on paper. Medicare requires that Medicare therefore for professional and supplier paper claims be the CMS 1500 claim form. Medicare therefore ssuppoers the implementation of the CMS 1500 claim form and its revisions for use by its professional providers and suppliers meeting an ASCA exception.

News Flash : Generally, Medicare Part B covers one fly vaccination and its administration per flu season for beneficiaries without co-pay or deductible. Now is the perfect time to vaccinate beneficiaries. Health care providers are encouraged to get a flu vaccine to help protect themselves from the flu and to keep from spreading it to their family, co-workers and patients.

Note: The flu vaccine is not a Part-D covered drug.