Ask the Contractor Teleconference

August 11, 2005

Topic: Advance Beneficiary Notice (ABN)

Questions & Answers

1. Does an ABN need to be signed before the actual service?

An ABN needs to be signed in a reasonable time before the service is rendered.

2. If an ABN has previously been signed, does the GA modifier have to be used on future claims?

The GA modifier should be used on every claim for wihich you have the ABN.

3. What modifiers would be used if maintenance physical therapy is rendered under a plan of treatment and an ABN is obtained?

Use modifiers GA and GP.

4. Can an ABN be date ranged?

If the same procedure and diagnosis applies, an ABN can be date ranged up to a year.

5. Who and who doesn't need an ABN?

The coverage criteria attached to a service will determine if an ABN applies. ABNs should not be obtained routinely.

6. Does a screening MRI need an ABN?

Since a National Coverage Determination applies to MRIs, an ABN would apply for any those conditions contraindicated or non-covered indications.

7. If a patient is on a Medicare Advantage Plan and the provider is not a Medicare Advantage provider, does an ABN apply?

The provider should contact the Medicare Advantage Plan to determine if the patient is liable.

8. If a screening pap smear has been rendered and a doctor sends a specimen to a lab, how do we get an ABN if the doctor did not obtain an ABN?

The lab is ultimately liable for obtaining an ABN for their service if they think Medicare will not pay. Since screening pap smears have frequency limitations attached to them, the doctor may have an ABN signed every time, especially if the doctor is having difficulty knowing which screening pap smears are covered. The ABN would apply for both the doctor's and lab's services.

9. If a waiver is signed but the GA was not submitted on the claim, is a copy of the ABN need to be provided if the claim is appealed?

Yes.

10. Does an ABN need to be obtained if the service is non-covered like routine exams?

Since routine exams are not covered by Medicare, the optional Notice of Exclusion of Medicare Benefits (NEMB) form may be obtained.

11. If the Medical Nutrition Therapy is rendered, but the diagnosis is not covered, who is responsible for obtaining the ABN?

The rendering provider.

12. If non-covered supplies are purchased from a physical therapy clinic but there is no prescription or ABN signed, can the patient be billed at the time of service?

      The patient responsibility should be collected after the service is billed and the Medicare Remittance Notice received.  

13. What should be done if the patient refuses to sign the ABN?

The service can still be rendered but the ABN should be noted with “patient refuses to sign ABN” and a witness signature obtained.

For additional information:

ABN instructions & ABN & NEMB forms

http://www.cms.hhs.gov/medicare/bni/

LCDs

CA http://www.medicarenhic.com/cal_prov/policies.shtml

NE http://www.medicarenhic.com/ne_prov/policies.shtml

NCD:  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd

10/13/2005