Yes, you must obtain an Advance Beneficiary Notice of Noncoverage (ABN) before providing the specified procedure or service to the patient if you think that Medicare may not cover a procedure or service.
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.
Let’s review when, why, and how you should use an ABN form and what ABN modifiers to use:
What is an Advance Beneficiary Notice of Noncoverage (ABN)?
An ABN is a Medicare waiver of accountability that providers needed to give to a Medicare patient for services provided that may not be covered or considered medically unavoidable.
The ABN must be completed and signed by the patient before providing services or items that are not covered by insurance. Do not continue with the procedure until the patient signs an ABN and accepts financial responsibility for non-covered services. Always file the signed ABN in the patient’s medical records.
Changes in the ABN Form
After August 31, 2020, one must use the new Medicare Fee-for-Service (FFS) ABN CMS-R-131 form with the expiration date of 6/30/2023 because CMS is retiring the old ABN (version 03/2020). The updated ABN form can be located on the CMS website under Beneficiary Notices Initiative, Downloads section. The form is available in English and Spanish.
Guidelines for dually-eligible beneficiaries i.e patients who have both Medicare and Medicaid were added to the ABN form instructions to comply with billing restrictions for patients in a Qualified Medicare Beneficiary (QMB) program. Have dually-eligible Medicare beneficiaries check Option Box 1 on the ABN form for a claim to be submitted for Medicare adjudication (the process of paying or denying claims).
Do Medicare Advantage Plans and Commercial Non-Medicare Plans Require ABNs?
Medicare Advantage Plans, also known as MA, Medicare Part C, or Medicare replacement, usually have separate rules, and they may or may not require an ABN. Always review the Medicare Advantage plans.
Some commercial non-Medicare plans are starting to require healthcare providers to obtain ABNs when the insurance plan does not cover a procedure or service, and when the patient is responsible for out-of-pocket expenses. You can modify the Medicare Part B ABN form and replace the word Medicare with the name of the medicare insurance carrier.
Modifiers Required When Billing With An ABN
Modifiers are added to the Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes to identify why a doctor or other qualified healthcare professional provided a specific service and procedure.
Payer rules for how to use modifiers differ with specific HCPCS and CPT billing codes. All modifiers can not be used with HCPCS or CPT codes.
Any procedures provided that require an ABN must be submitted with one of the following Medicare modifiers:
Modifiers GX and GY are used for items or services that are statutory excluded (services that are never covered) from Medicare.
Modifier GX Notice of Liability Issued, Voluntary Under Payer Policy. It indicates that you issued a voluntary ABN for services not covered because these services are statutorily excluded or are not Medicare benefits. You can use modifier GX with the modifier GY.
Modifier GY Notice of Liability Not Issued, Not Required Under Payer Policy. You do not need the patient to sign an ABN. This modifier is used to obtain a denial on a non-covered service. You can use modifier GY with the GX modifier.
Modifiers GA and GZ are used when a procedure or service is not reasonable and medically necessary as determined by a Medicare LCD or NCD.
Modifier GA Waiver of Liability Statement Issued as Required by Payer Policy. It indicates that you have an ABN on file for the patient, and this allows you to bill the patient if the procedure is not covered.
Modifier GZ Item or Service Expected to Be Denied as Not Reasonable and Necessary. It indicates that you issued an ABN for services that are not covered, and you expect Medicare to deny the payment. This is an informational modifier only.
An ABN gives a beneficiary the opportunity to make an informed decision prior to the item or service being provided to decide whether to receive it and accept financial responsibility.
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