Medicare Advance Beneficiary Notice (ABN): A Quick How To

Does Your Medicare Patient Need To Sign An Advance Beneficiary Notice (ABN) CMS-R-131?

Insurance Claim RejectedYes!  When applicable, your Medicare patients should always sign an Advance Beneficiary Notice (form CMS-R-131). An ABN is not used for commercial insurance companies.

What Is An ABN?

An ABN is a Medicare waiver of liability that providers are required to give a Medicare patient for services provided that may not be covered or considered medically necessary.

  • An ABN is used when service(s) provided may not be reimbursed by Medicare.
  • If the healthcare provider believes that Medicare will not pay for some or all of the items or services, an ABN should be given to the patient.
  • Examples of services that require an ABN include a visual field exam for an ophthalmologist, a pelvic exam for a primary care provider, or an echocardiogram.  These exams should be covered as long as they are medically necessary.
  • The complete CMS ABN manual is available at:  http://www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

Why is an ABN Important?

Reimbursement!  The patient will be personally responsible for full payment if Medicare denies payment for a specific procedure or treatment.

  • The ABN must be given to the patient prior to any provided service or procedure.
  • If there is no signed ABN then you cannot bill the patient and it must be written off if denied by Medicare.

ABNs Also Protect Your Patient

An ABN notifies Medicare that the patient acknowledges that certain procedures were provided.

  • It also gives the patient the opportunity to accept or refuse the item or service and protects the patient from unexpected financial liability if Medicare denies payment.
  • An ABN offers the patient the right to appeal Medicare’s decision.

When Do ABNs NOT Apply?

ABNs do not apply to services that are specifically excluded from Medicare coverage, such as an annual or a refractive eye exam.  Providers are not required to provide ABNs for these types of excluded services.

ABNs only apply to patients who are enrolled directly with Medicare, not patients who have coverage through a Medicare product from a private insurance company.

Proper ABN Completion

ABNs can be found on the Medicare website and have specific components that must be filled out properly in order for it to be a valid ABN.

  • Patient’s name, specific service and estimated charge amount must be listed on the ABN.
  • The ABN cannot be given to a patient who is under duress or requires emergency treatment.
  • Check for specific the criteria and download the form:  http://www.cms.gov/BNI/02_ABN.asp

Modifiers Required When Billing With An ABN

Any procedures provided that require an ABN must be submitted with one of the following Medicare modifiers:

  • GA Modifier: Waiver of Liability Statement Issued as Required by Payer Policy.  This modifier indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare.
  • GX Modifier: Notice of Liability Issued, Voluntary Under Payer Policy.  Report this modifier only to indicate that a voluntary ABN was issued for services that are not covered.
  • GY Modifier: Notice of Liability Not Issued, Not Required Under Payer Policy.  This modifier is used to obtain a denial on a non covered service.  Use this modifier to notify Medicare that you know this service is excluded.
  • GZ Modifier: Item or Service Expected to Be Denied as Not Reasonable and Necessary.  When an ABN may be required but was not obtained this modifier should be applied.

The Medicare Learning Network is a great resource tool and available to providers at: http://www.cms.gov/MLNGenInfo/

Medicare Billing Services

About Manny Oliverez

has years of healthcare, business and teaching experience. He has a passion for helping physicians get paid for the work they do. Manny likes to blog, act and cook. READ MORE
Post Written by:

Comments

  1. For long term clients who wish to continue therapy despite the fact that Medicare almost assuredly won’t pay, when am I able to stop billing Medicare and shift to private pay? a) Must I first get a denial using a GZ modifier? b) Must I bill Medicare regardless each time I send a private pay bill to the client — even if it’s months after the first denial?

    Thank you.

    • Kathryn with patients that want to continue therapy for the same course of treatment we bill Medicare using a GZ modifier to get the denial. In general, after the first denial, the patient can be switched to self pay. Medicare considers the extra visits as maintenance visits which are not covered. We do not bill Medicare each time after the first denial because we switch the patient to private pay since they have used up their Medicare benefits. Check the rules from your local Medicare carrier to see how they want you to handle the claims. You can find billing information on their website.

      Hope this helped. –Manny

  2. I just added this weblog to my feed reader, great stuff. Can’t get enough!

Leave me a Comment

*