When and How to Use an ABN

Our practice receives numerous questions from clients regarding the Centers for Medicare & Medicaid Services (CMS) Advanced Beneficiary Notice of Noncoverage (ABN) for Medicare claims. The ABN and the associated modifiers can be confusing, so this article addresses when ABNs should be used, when they are valid, and which modifiers are appropriate.

The ABN exists to provide patients with the information they need to make informed decisions about whether they want to receive prescribed services that may not be reimbursed by their Medicare plan. ABNs should be executed when services are usually covered by Medicare but are not expected to be paid, for reasons such as a lack of medical necessity, delivery of a same or similar item or service, or an experimental item or service. ABNs are not required for non-covered or excluded services, or services that are not a defined Medicare benefit.

ABNs are only valid when all sections of Form CMS-R-131 are completed, and the form is signed prior to delivery, which gives the patient ample time to make an informed decision. If the ABN is incomplete, the patient cannot be held responsible for financial liability. Some common situations in which ABNs are invalid include the following:

Blanket ABNs are when an ABN is obtained for all Medicare claims or services. ABNs must not be used for every Medicare service provided. ABNs should only be used if there is good reason to believe Medicare will not pay for services. The reason must be detailed on the form.

Generic ABNs are just that; the reason for likely denial is not detailed on the form. This nonbinding type of ABN explains that a Medicare denial is possible but does not detail why.

Signed Blank ABNs are invalid because providers cannot have beneficiaries sign blank ABNs. ABNs must be completed in full prior to delivery of the product or service, again so beneficiaries are fully informed about their options.

In addition to the previous conditions that invalidate ABNs, there are some important reminders from CMS about completing the ABN:

The patient or patient representative must sign and date the form. If someone other than the patient signs, you must identify why the patient could not sign and who the representative is. The patient must receive a copy of the ABN. The provider should retain the original. ABNs should be kept on file for five years. The following are the modifiers to use with an ABN, including the appropriate scenario in which to use each one:

GA: Waiver of Liability Statement Issued as Required by Payer Policy

GA should be used when an item or service is expected to be denied as not medically necessary, and a compliant ABN is on file. This modifier does not automatically cause a claim denial, but in the event of a denial the patient is financially responsible.

GX: Notice of Liability Issued, Voluntary Under Payer Policy

This modifier is used when a voluntary ABN is executed for non-covered services. Usage of this modifier will automatically deny the claim to patient liability. This modifier is used in conjunction with the GY modifier, which tells Medicare that you are billing for an item or service that is statutorily excluded or does not meet the definition of a Medicare benefit.

GZ: Item or Service Expected to Be Denied as Not Reasonable and Necessary

GZ is used when the services are expected to be denied as not reasonable and necessary, but no ABN was executed. Usage of this modifier will cause a denial and the services will not be subject to complex medical review.

When executed properly, the ABN is a helpful tool that allows your patients to make informed and educated decisions about the financial side of their care. Since ABNs should be obtained prior to delivery, it is important that all administrative staff and practitioners are educated on the proper execution of ABNs.

To download an ABN form, with instructions about how to correctly fill out ABN form CMS-R-131, visit https://go.cms.gov/1JWmDQ7 . You may also view a tutorial about completing an ABN form at https://www.youtube.com/watch?v=RPD2oMNtK1M .

While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.

Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at erin@cbsmedicalbilling.com .

When and How to Use an ABN

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