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 Beginning March 1, 2009, the ABN-G and ABN-L was no longer valid; and notifiers must use the revised Advance Beneficiary Notice of Noncoverage (CMS-R-131).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.

Medicare Part B advance beneficiary notices AND ITS MODIFIER

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).

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.

GA modifier and appeals

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 the modifier GA(wavier of liability statement on file).

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.

Nonassigned claims containing the modifier GA in which the patient has been found liable must have the patient’s written consent for an appeal. Refer to the Address, Phone Numbers, and Websites section of this publication for the address in which to send written appeals requests.

CLAIM INSTRUCTIONS WHEN A VALID ABN IS ON FILE - Modifier usage

When the previous instructions have been followed and a valid ABN on file, the following modifiers should be used to notify Medicare:

• GA Use to indicate that an ABN was given as required by payer policy. A copy of the ABN does not have to be submitted but must be made available upon request.

• GX Used to indicate that an ABN was given voluntarily under payer policy (UB-04) claims.

• GZ Use when an item or service is expected to be denied as not reasonable and necessary and an ABN has not been signed. Effective July 1, 2011, all claim line items submitted with a GZ modifier will be denied automatically and will not be subject to complex medical review.

Note: For billing submitted on a UB-04 claim form, occurrence code 32 should be included on the claim to indicate the date the ABN was given.

HOW THE ABN PROTECTS THE PROVIDER

WHAT IS AN ABN? 

An ABN is a written notice that a provider/supplier gives to a Medicare patient before items or services are rendered when the provider/supplier believes Medicare probably/certainly will not pay for some or all of the items or services.

ABNs should only be provided to Medicare beneficiaries. The ABN allows the beneficiary to make an informed decision about whether to receive services that he may be financially responsible for paying. The ABN serves as proof the patient had knowledge prior to receiving the service that Medicare might not pay. If a provider does not deliver a proper ABN to the patient, the patient cannot be billed for the service.

Note: Providers may not issue ABNs to shift financial liability to a beneficiary when full payment is made through bundled payments (e.g., National Correct Coding Initiative). ABNs cannot be used when the beneficiary would otherwise not be financially liable for payments for the service because Medicare made full payment.

Note: The newly revised ABN replaces the following notices: 

 ABN-G (CMS-R-131-G).

 ABN-L (CMS-R-131-L).

 Notice of Excluded Medicare Benefits (NEMB) (CMS-20007).

HOW THE ABN PROTECTS THE PROVIDER

      When a valid ABN has been given, the provider is free to bill the patient for the denied services.

      If an ABN is not valid, the provider may not bill the patient for the services. 

      ABNs may not be used to bill patients for services that are denied as bundled into other payments.

Effective usage of ABN notice

HOW TO EFFECTIVELY DELIVER AN ABN

ABN delivery is considered to be effective when the notice is:

•      Delivered and comprehended by a suitable recipient. 

•      The correct ABN approved notice with all required blanks completed.

Note: Failure to use the correct notice may lead to providers being found liable.

•      Delivered to the beneficiary in person if possible.

•      Provided far enough in advance of potentially non-covered items or services to allow sufficient time for the beneficiary to consider all available options.

•      Explained in its entirety and all beneficiary-related questions are answered.

•      Signed by the beneficiary or his representative.

Options for Delivery Other Than In-Person

In circumstances when in-person delivery is not possible, an ABN may be delivered through the following means:

•      Telephone.

•      Mail.

•      Secure fax machine.

•      Internet e-mail.

When delivery is not in-person, the contact must be documented in the patient’s records. To be considered effective, the beneficiary cannot dispute such contact. Telephone contacts must be followed immediately by either a hand-delivered, mailed, e-mailed or faxed notice. The beneficiary or representative must sign and retain the notice and send a copy of this signed notice to the provider for the retention in the patient’s record.

The provider must keep a copy of the unsigned notice on file while awaiting receipt of the signed notice. If the beneficiary does not return a signed copy, the provider must document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself.

Medicare ABN exclusion cases

WHEN SHOULD AN ABN BE GIVEN?

Mandatory ABN Uses

An ABN should be given when Medicare is expected to deny payment (entirely or in part) for the item or service because it is not reasonable and necessary under Medicare program standards.

Voluntary ABN Uses

ABNs are not required for care that is statutorily excluded. However, the ABN can be issued voluntarily in place of the NEMB.


Examples of Medicare program exclusions are:

•      Personal comfort items.

•      Self-administered drugs and biologicals (i.e., pills and other medications not administered by injections).

•      Cosmetic surgery (unless required for prompt repair of accidental injury or for improvement of a malformed body member).

•      Eye exams for the purpose of prescribing, fitting or changing eyeglasses or contact lenses in the absence of disease or injury to the eye.

•      Routine immunizations (except influenza vaccine, pneumococcal vaccine and hepatitis B vaccine; these services have specific regulations regarding patient responsibility).

•      Physicals, laboratory tests and X-rays performed for screening purposes (except screening mammograms, screening Pap smears and various other mandated screening services; these services have specific guidelines regarding patient responsibility and when an ABN should be obtained).

•      X-rays and physical therapy provided by chiropractors.

•      Hearing aids and hearing examinations.

•      Routine dental services (i.e., care, treatment, filling, removal or replacement of teeth).

•      Supportive devices for the feet.

•      Routine foot care (i.e., cutting or trimming corns or calluses, unless inflamed or infected; routine hygiene or palliative care or trimming of nails).

•      Custodial care.

•      Services furnished or paid by government institutions.

•      Services resulting from acts of war.

•      Charges made to the Medicare program for services furnished by a physician or supplier to his immediate relatives or members of his household. The following relationships are included in the definition of immediate relative: husband and wife; natural parent, child and sibling; adopted child and adoptive parent, adopted sibling; stepparent, stepchild, stepbrother and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law and sister-in-law; grandparent and grandchild; and spouse of grandparent or grandchild. By definition, members of the household include those persons sharing a common abode with the physician as part of a single family unit, including those related by blood, marriage or adoption; domestic employees; and others who live together as part of a single family unit.