1. Is an ABN required for statutorily excluded items or services?
ABNs are not required for care that is either statutorily excluded from coverage under Medicare (i.e., care that is never covered) or most care that fails to meet a technical benefit requirement (i.e., lacks required certification). However, CMS strongly encourage healthcare providers and suppliers to issue the ABN for care that is never covered.
is located on the CMS website as well as on the Forms Catalog (JH
) page of our website.
2. A physician orders a lab test; the specimen is collected in the physician's office and sent to the lab for processing. Is the lab or physician responsible for executing the ABN?
When multiple entities are involved in rendering care, it is not necessary to give separate ABNs. Either party involved in the delivery of care can be the notifier when:
There are separate “ordering” and “rendering” providers (e.g., a physician orders a lab test, and an independent laboratory delivers the ordered tests).
One provider delivers the “technical” and the other the “professional” component of the same service (e.g., a radiological test that an independent diagnostic testing facility renders, and a physician interprets); or
The entity that obtains the signature on the ABN is different from the entity that bills for services (e.g., when one laboratory refers a specimen to another laboratory, which then bills Medicare for the test).
Regardless of who gives the notice, the billing entity is responsible for effective delivery. When the notifier is not the billing entity, the notifier must know how to direct the beneficiary who received the ABN to the billing entity itself for questions and should annotate the Additional Information section of the ABN with this information. It is permissible to enter the names of more than one entity in the header of the notice.
3. How do I determine if an ABN is required for a screening, such as mammography or prostate specific antigen?
You can verify prior screening information through the interactive voice response unit or Novitasphere.
For any item or service for which Medicare has established a regulatory frequency limitation on coverage, routinely issued ABNs are permitted.
Additional information on the ABN
is located on the CMS website.
4. When would I report modifier GA?
Report modifier GA to indicate that the beneficiary received an advance written notice of the likelihood of denial of a service as being not reasonable and necessary under Medicare guidelines.
Bill services with modifier GA as covered.
Do not report modifier GA in association with any other liability-related modifier.
5. When would I report modifier GY?
Report modifier GY when you believe a service will deny because the service is a statutory exclusion or does not meet the definition of any Medicare benefit.
Append the GY modifier on non-covered line items on a claim with other covered services.
6. What do we do if the beneficiary refuses to sign an ABN?
If the beneficiary refuses to choose an option and/or refuses to sign the ABN when required, the notifier should annotate the original copy of the ABN indicating the refusal to sign or choose an option and may list witness(es) to the refusal on the notice although this is not required. If a beneficiary refuses to sign a properly delivered ABN, the notifier should consider not furnishing the item/service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.
In any case, the notifier should provide a copy of the annotated ABN to the beneficiary and keep the original version of the annotated notice in the patient’s file.
7. Who is authorized to sign an ABN if a beneficiary is unable to sign?
An individual who may make health care and financial decisions on a beneficiary’s behalf (e.g., the beneficiary’s legal guardian or someone appointed according to a properly executed “durable medical power of attorney”) is an authorized representative.
If the beneficiary has a known, legally authorized representative, the ABN must be issued to the existing representative.
If a beneficiary does not have a representative and one is necessary, a representative may be appointed for purposes of receiving notice following CMS guidelines and as permitted by state and local law.
When a representative is signing the ABN on behalf of a beneficiary, the ABN should be annotated to identify that the signature was penned by the “rep” or “representative”. If the representative’s signature is not clearly legible, the representative’s name should be printed on the ABN.
8. How do I bill a non-covered Part A service with an ABN?
An ABN is a written notice you give to the beneficiary before rendering a service when you believe Medicare will not pay on the basis that the service may not be medically necessary. When the beneficiary signs an ABN, you must report occurrence code 32 and modifier GA.
Submit services reported with modifier GA as covered.
9. Can modifications be made to the ABN?
Providers/notifiers may do some customization of ABNs, such as pre-printing information in certain blanks to promote efficiency and to ensure clarity for beneficiaries.
Providers/notifiers may create multiple versions of the ABN specialized to common treatment scenarios using the required language and general formatting of the ABN.
Blanks (G)-(I) must be completed by the beneficiary or their representative when the ABN is issued and may never be pre-filled.
Lettering of the blanks (A-J) should be removed prior to issuance of an ABN.
If pre-printed information is used to describe items/services and/or common reasons for noncoverage, clearly indicate on the ABN which portions of the pre-printed information are applicable to the beneficiary.
Providers who pre-print a list of items/services may wish to list a cost estimate beside each item/service.
ABN's may not be modified except as specifically allowed by these instructions. Please be cautious before adding any customizations beyond these guidelines, since too many changes to ABNs may result in an invalid notice and provider liability for noncovered charges.
10. Where can I find ABN forms?
You can find all ABNs
forms on the CMS website.
11. How often must an ABN be given to a beneficiary receiving repetitive services?
An ABN can remain effective for up to one year. The ABN must describe an extended or repetitive course of noncovered treatment as well as a list of all items and services believed to be non-covered. If applicable, the ABN must also specify the duration of the period of treatment. A new ABN is required when the specified treatment extends beyond one year. If, during treatment additional noncovered items or services are needed, another ABN must be given.