Ask the Contractor Teleconference

March 17, 2006

Topic: Advance Beneficiary Notice (ABN)

Questions and Answers

Question 1: Do ABNs apply to Durable Medical Equipment?

Answer 1: For the limitation of liability rules that apply to DME, you would need to contact the Durable Medical Regional Carrier (DMERC).

For the CA DMERC contact CIGNA Medicare at (866) 243-7272

For the NE DMERC contact HealthNow NY at (866) 419-9458

Question 2: If a Physical Therapy claim gets paid and then gets reviewed on a post payment basis and Medicare requests the money back, who is responsible for the balance?

Answer 2: The patient is responsible if they have signed an ABN.

Question 3: Does the date and cost need to be completed on the ABN?

Answer 3: The date must be completed. The estimated cost does not need to be completed unless the beneficiary requests

Question 4: When we bill for non-covered Ambulatory Surgery Center fees, is it appropriate to use

the GY modifier?

Answer 4: Non-ASC approved services will be denied with or without the GY modifier. However

ASC’s should inform their patients that a non-approved procedure will not be paid by Medicare, and

a GY modifier should be used to let Medicare know you are submitting this code for a denial.

Question 5: Is a tetanus injection (90718) for V06.5 (tetanus-diphtheria) an ABN issue?

Answer 5: Tetanus Toxoid is covered when there is a break in the epidermis and where there is risk of exposure to the tetanus organism. Tetanus injections for other reasons are statutorily excluded and therefore the ABN would not apply. If 90718 is submitted with V06.5, it would deny with a Patient Responsibility (PR) Remark Code. The Notice of Exclusions from Medicare Benefits (NEMB) form may be used.

Question 6: If the patient refuses to sign the ABN, is the patient responsible for the balance?

Answer 6: If a witness signs the ABN and the patient has the service rendered, the GA modifier would be used and the patient would be responsible if the service denies.

Question 7: Do ABNs apply to Program Coverage Issues? Sometimes, the Ambulatory Surgery Center

code that our coder uses ends up being non covered.

Answer 7: ABNs do not apply to Program Coverage Issues. If the expected denial is not a medical

necessity, the ABN does not apply. If a service is statutorily excluded from the program and is never

covered, the patient could sign an NEMB, but would not be required to sign an ABN. Refer to the

ASC fee schedule to see what codes are covered.

Question 8: When a specimen is taken at a physician’s office and sent to a lab for testing, who is responsible for getting the ABN to the lab?

Answer 8: Since the physician has contact with the patient, they physician should forward a copy of the ABN to the entity that will ultimately bill Medicare for the service. In the case where there is no patient contact, the entity is responsible for obtaining the ABN.

3/30/2006