Advanced Beneficiary Notice (ABN) Advisory

The CMS form CMS-R-131 is a standardized notice that you must issue to a Medicare beneficiary before providing certain Medicare Part B (outpatient) or certain Part A items or services.

You must issue the ABN when:

• You believe Medicare may not pay for an item or service,
• Medicare usually covers the item or service, and
• Medicare may not consider it medically reasonable and necessary for this patient in this particular instance.

You should only provide ABNs to beneficiaries enrolled in Original (Fee-For-Service) Medicare. The ABN allows the beneficiary to make an informed decision about whether to receive services and accept financial responsibility for those services if Medicare does not pay. The ABN serves as proof that the beneficiary knew prior to receiving the service that Medicare might not pay.

If you do not issue a valid ABN to the beneficiary when Medicare requires, you cannot bill the beneficiary for the service and you may be financially liable.

The ABN also serves as an optional (voluntary) notice that you may use to forewarn beneficiaries of their financial liability prior to providing care that Medicare never covers. Medicare does not require you to issue an ABN in order to bill a beneficiary for an item or service that is not a Medicare benefit and never covered.

You should issue the ABN to:

• The Medicare beneficiary or
• The Medicare beneficiary’s representative for the purposes of getting notice under applicable state or other law.

You and the beneficiary must each retain one copy of the signed ABN. If you are using Glenwood’s EMR, you may scan the signed hard copy for retention.

The following are claim modifiers should be added when using ABNs:

GA: Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case

Use this modifier to report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN with the claim but you must have it available upon request.

GX: Notice of Liability Issued, Voluntary under Payer Policy

Use this modifier to report when you issue a voluntary ABN for a service that Medicare never covers because it is statutorily excluded or is not a Medicare benefit.

GY: Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit

Use this modifier to report that Medicare statutorily excludes the item or service or the item or service does not meet the definition of any Medicare benefit.

GZ: Item or Service Expected to Be Denied as Not Reasonable and Necessary

Use this modifier to report when you expect Medicare to deny payment of the item or service due to a lack of medical necessity and no ABN was issued.

Medicare prohibits you from issuing ABNs on a routine basis (i.e., having patients sign an ABN prior to every visit regardless of what will be done that day). You must ensure that a reasonable basis exists for non-coverage associated with the issuance of each ABN. Some situations may require a higher volume of ABN issuance, and as long as proper evidence supports each ABN use, you will not be violating the routine notice prohibition.

You should not obtain an ABN from a beneficiary in a medical emergency or under great duress (i.e., compelling or coercive circumstances). ABN use in the emergency room may be appropriate in some cases for a medically stable beneficiary with no emergent health issues.

Voluntary ABN Uses

Medicare does not require ABNs for statutorily excluded care or for services Medicare never covers. However, in these situations, you may issue an ABN voluntarily. Examples of Medicare Program exclusions include:

• 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, pneumococcal, and hepatitis B vaccinations; specific regulations regarding beneficiary responsibility apply for these services)
• X-rays and physical therapy provided by chiropractors
• Hearing aids and routine 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)
• 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 or her immediate relatives or members of his or her household

For more information including a copy of the ABN and instructions visit http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.

Source: www.cms.gov