Advance Beneficiary Notice for Physicians - An Overview

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Advance Beneficiary Notice (ABN) for Physicians
an Overview
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• Advance Beneficiary Notice of Non-coverage (ABN)
  is a form from CMS (Center for Medicare and
  Medicaid) that providers can give their patients,
  if they believe that Medicare will deny payment
  for a service because it is not medically
  necessary.
• The issuing of ABN form allows the beneficiary to
  make an informed decision about whether to get
  the service that may not be covered and accept
  financial responsibility if Medicare does not
  pay.
• Professional medical billing companies can assist
  physicians with their billing, coding and claim
  submission tasks, but it is important for
  physicians to have a clear idea regarding
  Medicares Advance Beneficiary Notices (ABN) and
  whether or not to issue the form before providing
  any service.

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• ABN Two Types
• Required ABN - for the service that is a benefit
  of Medicare but not paid due to restricted
  coverage
• Voluntary ABN - for the service that is not a
  benefit of Medicare, which is never payable

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• ABN Can Be Issued, If
• They believe Medicare may not pay for an item or
  service
• The patient is not terminally ill, and
• The service provided is not medically reasonable
  and necessary for this beneficiary

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• ABN Cannot Be Issued
• If the provider does not have a specific reason
  to believe the service will be denied
• After the exam has already been performed, or
  when the patient has already been prepped and
  is about to begin the exam
• To make the patient pay for a bundled service
• If it is an emergency situation

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• Use the Right Modifier
• The claim must be noted with the correct
  modifier.
• GA modifier is used to issue a mandatory ABN for
  a service as required and it is on file.
• GX modifier is used to issue a voluntary ABN for
  a service Medicare never covers as it is
  statutorily excluded, or is not a Medicare
  benefit.
• Use GY, if the service is not a benefit of
  Medicare in any definition. It can be billed in
  combination with GX if the patient signed an ABN
  and is liable.
• GZ is used for service that is expected to be
  denied and an ABN was not issued and beneficiary
  is not liable.
• ABN guidelines can be referred in detail in the
  CMS booklet on Medicare Advance Beneficiary
  Notices.

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1-800-670-2809
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Contact Us
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HTulsa, OK 74133Main [phone]
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