Does Your Medicare Patient Need To Sign An Advance Beneficiary Notice (ABN) CMS-R-131?
Yes! 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/
Hello,
Medicare has refused 3 appeals. I have the Medicare form signed by my husband’s specialist that his ambulance services were necessary. Now they say that since he has passed, the 3rd
appeal is denied. I already offered proof of
Our marriage. The same person
Denied my first two claims. Do you have any posts regarding denied appeals? Thank you
Hello Manny,
How should we bill when we are expecting a denial from Medicare? We have to bill Medicare and get a PR96 in order for the secondary payer to pay our claims. This year our claims are not processing correctly since the DIF is no longer required.
Can we bill with GY & GZ together? Currently we bill with GA if the ABN is on file and leave it blank if it wasn’t returned, or sometimes we but the GY.
How do I report a clinic for not having any of their Medicare patients sign an ABN?
Are ABNs for traditional Medicare ONLY, with no Part D coverage?? No supplemental plans or secondary coverage? Medicare RX plans?
you say an ABN should not be used if the member has commercial insurance, however this is where I disagree. Here is my example, if a member comes in with an Rx for a walker or a breast pump, without an ABN we bill the insurance and it gets denied for same/ similar as a frequency denial. I say with an ABN I can bill the customer but without the ABN, the insurance company dictates to me that we did not do our job in calling them for same or similar. My bitch is the insurance company would not give us this information and that we asked the customer and they lied to us committing fraud on their end. It’s a way to prevent fraud and put the fraudulent act to the customer/ member and not the provider. Do you agree?
An ABN is specific to Medicare. What you are thinking about is a waiver. It’s basically the same thing but you would word it differently.
If we provide private pay caregivers to clients do we have to have them sign a ABN?
Aloha,
I am a DME provider of medical-grade compression garments exclusively and do not take insurance other than VA and Tricare.
If a patient happens to be a medicare patient do I still need them to fill out an ABN ?
For the amount quoted on an ABN can it be our self-pay rate or does it need to be the amount Medicare would allow if the procedure was covered? Our physician is performing a breast reduction which has an allowable of around $1,500 but she wants to quote $3,000 on the ABN.
Amazing site. I can not believe I found this its awesome and can help me understand all of it. Thank you
I’m not a physician, but a patient. I was recently charged $380 as a “facility fee” which I later learned was office rent. That was in addition to my physician’s fee. I was not informed beforehand nor afterwards. Is that really legal? Medicare paid, but it was not listed to them as a facility fee. It wasn’t until I dug deep with a billing rep that I was told what it was for.
What codes do you bill with Medicare for a patient with a annual pap smear? Is it G0439, G0101, and Q0091 with modifier GA.
i have a claim for a DME where the patient signed and choose option 1 on the ABN and Medicare denied advising benefit maximum for this time period or occurrence has been reached.
Can someone tell me what modifier should i use for this scenario? thanks in advance 🙂
kx
I have recently started working for Primary Care Doctor and they sometimes give DME products like a post op shoe. Would I have Medicare patients sign an ABN for DME products?
Great site, thank you for posting something relevant and helpful!
For Medicare patients within an ACO is an ABN still applicable?
We don’t deal with ACOs but my understanding is that ABNs are still applicable. I would contact my local Medicare carrier.
Invaluable analysis, For my two cents, if your company is interested a Form CMS-R-131, We found a sample form here https://www.cms.gov/MEDICARE/medicare-general-information/bni/abn.html
We have a patient who has reached the $3700 threshold and wants to come into our physical therapy practice for ultrasound therapy only (97035). Do we get an ABN signed since there are no studies showing its effectiveness and Medicare only pays based on medical necessity after the threshold is reached? Also, if the patient signs option 2, so we bill her the Medicare rate or our normal charge? (same for if she chooses option 1 and Medicare denies). Thank you!
Can you have a patient sign a blank ABN to keep on file in the chart.
When billing the LIDOS with a GA modifier (ABN Signed and appropriately delivered) our MAC is assigning patient responsibility for the allowed amount instead of total charges. Is this correct? If so, we should be quoting the patient based on the allowed amount instead of total charges?
A patient was given a TDAP injection, CPT codes 90715 GA and 90471 were billed. The patient has Medicare as primary and BCBS FL Federal as 2nd. Medicare denied as non-covered (PR-96), BCBS FL Fed came in a paid a portion (they paid what there plan allowed), the patient EOB says that due to our doctor being a preferred provider that the patient is not responsible for the difference between the submitted charges and there allowable charges. Since an ABN was signed (option 1) isn’t the patient still responsible for the difference? I am unsure how to explain this to the patient and/or am not sure if I used an incorrect modifier, etc.
Hi Tonya —
A couple things here, first the GA modifier would not be appropriate for this charge as it is a non-covered service from Medicare. A GX modifier would have been more appropriate. This modifier indicates that a voluntary ABN was issued for services that are not covered. It is a voluntary ABN becasue you don’t have to have one signed by the patient since Medicare does not cover the TDAP.
Secondly since you are par with Medicare you have to take the allowable charge unless it is a non-covered service, as in this case.
But wait, there is secondary insurance which I assume you participate with which means you have to take the allowable charge from BCBS. There is no Balance Billing the patient. An ABN does not allow you to balance bill a patient. It only allow you to bill the patient the allowable amount. Plus it is not applicable to commercial insurance, it’s only good for Medicare.
Looks you have collected all you can for the TDAP at this point. –Manny
Great site, thank you for posting something relevant and helpful!
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I just added this weblog to my feed reader, great stuff. Can’t get enough!
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
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