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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Use of the Medicare Advanced Beneficiary Notice (ABN)

December 21st, 2011

Many members have requested clarification on how to determine when an Advanced Beneficiary Notice of Noncoverage should be provided to Medicare patients. The intent of this article is to clarify this confusing area.

Advanced Beneficiary Notice of Noncoverage (ABN)

The ABN should be provided to a Medicare patient prior to rendering a service that Medicare might otherwise cover, however is likely to be denied on this particular occasion. For example, when you have good reason to expect the procedure will be denied based on other Medicare denials and local medical review policies, or that the patient's diagnosis or procedure does not meet the Medicare program standards for medical necessity.

The ABN is intended to provide the patient advanced notice that it is likely the procedure will be denied and allows the patient to make an informed decision whether to receive the service for which he or she may be personally responsible. Claims for such services may be submitted with either the HCPCS modifier "GA" ("waiver of liability statement issued as required by payer policy") or "GX" ("notice of liability issued, voluntary under payer policy"). If the service is denied and a signed ABN is not on file, the physician may not hold the patient responsible for payment.

There may be instances in which the service to be rendered is expected to be denied however a signed ABN was not obtained because the patient refused to sign it. If this is the case, the physician may choose not to render the service, unless the health and safety of the patient is at risk. Another scenario might be that the patient presents a medical emergency and under great duress in which EMTALA (Emergency Medical Treatment and Labor Act) provisions apply and therefore could not have been provided with an ABN prior to rendering treatment. In these situations, the claim may be submitted to Medicare, however the modifier "GZ" should be included on the claim form to indicate "item or service expected to be denied as not reasonable and necessary." Although in these situations Medicare will most likely hold the provider financially liable.

Remember it is unlawful to provide the ABN on a routine indiscriminate basis. The ABN is not intended to be a blanket statement to protect a physician from financial liability. Generic ABNs simply stating "Medicare will likely deny this service" are also unacceptable. The ABN should be provided when there is a specific reason to believe the service will be denied and the specific reason should be indicated.

Recent Centers for Medicare and Medicaid Services (CMS) changes to the ABN process included revision to the ABN form itself making the Notice of Exclusions from Medicare Benefits (NEMB) form essentially obsolete. A revised version of the Advance Beneficiary Notice (ABN) form became available March, 2011 and fully implemented January 1, 2012. The revised form has a new name: "Advance Beneficiary Notice of Noncoverage" however is still referred to as the "ABN".

Completing the cost-estimate field is critical to remaining in compliance. The form should continue to be provided to Medicare beneficiaries before rendering a service that is likely to be denied by Medicare. The revised form and instructions are available on the Beneficiary Notices page of the CMS Web site.

Medicare does not require claims to be submitted for non-covered services, such as dental care, cosmetic surgery, preventative medicine, and routine physical examinations. However, if the patient believes that a service may be covered, requests that a claim be submitted, or wishes to receive a formal Medicare determination for consideration by a supplemental insurance, a claim for the non-covered service must be submitted.

When submitting a claim for non-covered services, you may wish to apply the HCPCS modifier "GY" to the procedure code to indicate an item or service that is statutorily excluded or does not meet the definition of any Medicare benefit. Even though Medicare will "auto-deny" any procedure with the "GY" modifier, applying the modifier may speed the claims process and allow the patient to submit a claim to another carrier sooner. The "GY" may appear in addition to the "GX" when appropriate.

An ABN is not required when submitting claims for non-covered services, but rather is voluntary in these situations. Many providers prefer providing Medicare patients written notice that the service to be rendered is excluded from Medicare benefits. Doing so assures them that the patient has acknowledged that they will be responsible for payment. The ABN in these situations allows the patient to make an informed decision about whether or not they want to receive the service or treatment knowing that they will be personally financially responsible, and also allows them to be more active in their own health care treatment decisions.

Before electing to not obtain a signed ABN or submit a claim, it is imperative that you be certain that the service is statutorily excluded. If you charge a patient your standard fee for services that may possibly be covered, you may be charged with violating Medicare policy, and risk penalties or exclusion from Medicare and other federal health programs.

To download a copy of the ABN you may visit the Beneficiary Notices Section of the CMS Web site. For more information, view the CMS Medicare Learning Network "Advanced Beneficiary Notice of Noncoverage (ABN)" booklet which provides information on when providers should use an ABN, ABN policies, how to properly complete an ABN and ABN modifiers. To order your copy, free of charge, please visit the MLN Products page. Scroll down to the "Related Links Inside CMS" section and choose "MLN Product Ordering Page," or view the online version.

Local Coverage Decisions (LCD)

For those who find it difficult to determine whether a procedure is a covered Medicare benefit, Medicare has made it easier by posting national and local coverage policies on the CMS Web site. The Medicare Coverage Database allows a search for local and national policy by CPT code or by keyword.

Moreover, according to CMS Program Memorandum dated January 3, 2003, as of April 1, 2003, providers may notice a new remittance advice remark code "N115" accompanying procedures that were denied due to a local coverage decision. This will ease the tensions with determining when to provide an ABN.

N115 - "This decision was based on a local coverage decision (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.hhs.gov/mcd/search.asp."

Now that LCDs are easily accessible it is important to review your Medicare carrier's policies as interpretations of Medicare policy may vary from state to state. For example, some carriers will reimburse for the removal of tori, while others consider it an excluded service.