If an FI receives a completely non-covered claim with either a condition code 20 or a condition code 21, process the claim through all systems.
Beneficiaries are assumed to be liable on claims using condition code 21, since these claims, sometimes called “no-pay bills” and having all non-covered charges, are submitted to Medicare to obtain a denial that can be passed to subsequent payers. An advance beneficiary notice (ABN) is not required in these cases. If an ABN is given, condition code 21 cannot be used.
Claims with condition code 20 may be submitted with both covered and non-covered charges. An ABN, specifically Form CMS-R-131, should not be employed when condition code 20 is used. Note that condition code 20 may be used when: (1) a Home Health (HH) ABN, Form CMS-R-296, is used because payment will be made under the HH Prospective Payment System (PPS); or (2) a hospital or SNF inpatient notice of non-coverage is provided, since a Form CMS-R-131 will not be given in these cases.
Claims are billed with condition code 20 at a beneficiary’s request, where the provider has already advised the beneficiary that Medicare is not likely to cover the service(s) in question. Providers may directly collect payment from beneficiaries in such cases for non-covered charges, but if, upon review, Medicare decides a service in question is actually covered and pays, providers must return any payment collected from beneficiaries for these services. Medicare reviews all home health (HH)
and skilled nursing facility (SNF) services in question on these bills using condition code 20 to make a payment determination.
Occurrence code 32 on a claim signifies that an ABN, Form CMS-R-131, was given to a beneficiary on a specific date. This code must be employed if this specific ABN form is given, and condition code 20 will not be used on the subsequent claim (i.e., no charges will be submitted as non-covered). All services on such claims with occurrence code 32 must be covered charges, even if the result of full adjudication of these claims is expected to be that services will be found to be non-covered. If such services are non-covered after full adjudication, the beneficiary remains liable for the services.
If instead, as a result of medical review, Medicare finds services are covered, the Medicare Program becomes liable since the provider will receive payment direct from Medicare.
NOTE: The use of a provider ABN, Form CMS-R-131 and occurrence code 32 can apply to all outpatient or institutional Part B services, with three exceptions. One, only a HHABN, Form CMSR-296 and condition code 20, can apply to HH PPS services. Two, the provider ABN, Form R-131, and occurrence code 32 are to be used when needed for hospice services paid under either Trust Fund A or Trust Fund B. Three, a totally separate process will be used for ambulance claims containing non-covered miles; a new PM is currently in development for this ambulance situation.
Only services for which the ABN was given should be shown on the claim with occurrence code 32, since the code pertains to every service on the claim. Providers must give separate ABNs for different procedures if performed on different dates, and show the services and the dates ABNs were given on separate bills for each date involved. The one exception is that only one ABN is required for a series of services given under standing orders.
If a service not pertaining to the ABN was rendered in the same period as service(s) requiring an ABN, such services must be submitted on separate claims, and the statement dates of these claims cannot overlap. If the time periods cannot be separated (i.e., a service requiring an ABN is given on the same day a service not requiring an ABN), a single claim must be submitted, just for the overlapping period, using occurrence code 32, showing all services as covered, and placing modifier GA on the HCPCS code to identify the service (revenue code) line for which the ABN (Form CMS-R-131) was given. Since this is an exception process, providers are reminded to use this mechanism only when it is impossible to separate the billing periods.
The final instance in which beneficiaries are liable for non-covered charges is for services they request be billed to Medicare, but Medicare does not cover by statute. Examples of services not covered by statute include personal comfort items, hearing aides and hearing examinations, routine eye and dental care. Medicare claims processing edits are being refined to effectuate the processing of such claims. Providers should advise beneficiaries each time they are aware services not covered
by statute are being requested before Medicare is billed, but ABNs are not to be used in these cases.
If, in a situation in which giving an ABN, Form CMS-R-131 is not appropriate, a beneficiary demands a Medicare determination for any line(s) for other than HH PPS services, instruct the provider to put those line(s) on a separate bill showing the charges as non-covered and put condition code 20 on the bill. If a beneficiary wants an MSN for denial reasons on any line(s), instruct the provider to put those line(s) on a separate bill and show condition code 21 on that bill. If the provider gives the beneficiary an ABN under any other circumstances, the provider must show the charges as covered and also put occurrence code 32 on the claims to fix beneficiary liability. There are no provider billing requirements for billing services excluded by statute other than billing such items as non-covered. The SS will generate denial reasons for the lines containing non-covered charges. HH PPS services are addressed in a previous section of this instruction.
Billing With an ABN (Use of Occurrence Code 32) Comparable to Traditional Demand Bills
Now, using an ABN is frequently required, much more often than traditional demand billing, usually when medical necessity is in doubt, or when other issues captured in §1862(a)(1) and §1879 of the Act apply, or when previous covered treatment is to be reduced or terminated within a Medicare benefit. Previous ABN instructions brought about a large change in billing practices, because before these instructions, covered charges were never billed when medical necessity was in doubt.
Claims billed in association with an ABN, other than HHPPS and SNF PPS exceptions, never use condition code 20 or 21, and will be returned to providers if received, but instead:
Must use a claim-level occurrence code 32 to signify all services on the claim are associated with one particular ABN given on a specific date (unless the use of modifiers, discussed below, makes clear not every line on the claim is linked to the
• Must provide the date the ABN was signed by the beneficiary in association with the occurrence code;
Occurrence code 32 and accompanying date must be used multiple times if more than one ABN is tied to a single claim for services that must be bundled/billed on the same claim (i.e., one date for one ABN lab
services tied to a R-131-L, another for services tied to a R-131-G, even if the date is the same for both ABNs);
Must submit all ABN-related services as covered charges (note –GA modifier exception, below); and •
• Must complete all basic required claim elements as for other comparable claims for covered services.
Again, if an ABN is given, these billing procedures must be used, rather than traditional demand billing. New with this instruction, providers should be aware CMS may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN. Citations for instructions on the ABN, which include information on when an ABN is
appropriate, are given above. If claims using occurrence code 32 remain covered, they will be paid, RTP'ed, rejected or denied in accordance with other instructions/edits applied in processing to completion. Denials made through automated medical review of service submitted as covered are still permitted after medical review, and the FI will determine if additional documentation requests or manual development of these services are warranted. For all denials of services associated with the ABN, the beneficiary will be liable.
Condition Codes 20 and 21
If FIs receive a completely non-covered claim without either a condition code 20 or a condition code 21, process the claim through your system. All non-covered claims must be processed as provider liable unless occurrence code 32 and date is present signifying that an advance beneficiary notice was given to the beneficiary on that date, or, unless the service is non-covered by statute.
If a beneficiary demands a Medicare determination for any line(s) for other than Home Health services, instruct the provider to put those line(s) on a separate bill showing the charges as noncovered and put condition code 20 on the bill. If a beneficiary wants an MSN for denial reasons on
4 any line(s) for other than Home Health services, put those line(s) on a separate bill and show condition code 21 on that bill. The SS will generate denial reasons for the lines containing noncovered charges. Home Health services are addressed in a previous section of this instruction.
Note: The use of occurrence code 32 should be made specific to all claim types except Home Health bills. Since there is only one occurrence code (32) to indicate the date the beneficiary received an ABN, only lines for which you notified the beneficiary on the same date may be submitted on the same bill for both demand bills and billing for denial bills (condition codes 20 and 21). If you gave ABNs on different dates for different procedures, show the services and the dates you gave ABNs on separate bills for each date involved
In summary, other general requirements for demand bills are:
• Condition Code 20 must be used;
• All charges associated with Condition Code 20 must be submitted as non-covered;
• All non-covered services on the demand bill must be in dispute;
• At least one non-covered line must appear on the claim related to the services in dispute;
• Unrelated covered charges are allowed on the same claim;
• Unrelated non-covered charges not in dispute, if any, would be billed on a no payment claim using Condition Code 21;
• Frequency code zero should be used if all services on the claim are non-covered;
• Occurrence code 32 (i.e., ABN) is NEVER submitted on a claim using condition code 20; and
• Basic required claim elements must be completed. Claims not meeting these requirements will be returned to providers.
In using the ABN, beneficiaries select only one option on the ABN notice prior to billing, after they have been told that the provider anticipates Medicare will not cover a service. Claims, other than HHPPS claims, billed in association with an ABN never use condition code 20 or 21, and will be returned to providers if received with those codes. Instead, the claims: • Must use occurrence code 32 to signify all services on the claim are associated with one particular ABN given on a specific date, unless the use of modifiers makes clear that not every line on the claim is linked to the ABN;
• Must provide the date the ABN was signed by the beneficiary in association with the occurrence code;
• Must use occurrence code 32 and the accompanying date multiple times if more than one ABN is tied to a single claim for services that must be bundled/billed on the same claim;
• Must submit all ABN-related services as covered charges (note –GA modifier exception, below); and
• Must complete all the same basic required claim elements as comparable claims for covered services.
Providers should be aware CMS may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN.
If claims using occurrence code 32 remain covered, they will be paid, RTP’ed, rejected or denied in accordance with other instructions/edits applied in processing. Denials made through automated medical review of service submitted as covered are still permitted after medical review, and the Medicare contractor will determine if additional documentation requests or
manual development of these services are warranted. For all denials of services associated with the ABN, the beneficiary will be liable.
Line level coding
The –GA modifier is used when provider must bill some services which are related and some which are not related to a ABN on the same claim. The –GA modifier is used when both covered and non-covered service appear on an ABN-related claim. Occurrence code 32 must still be used on claims using the –GA modifier, so that these services can be linked to specific ABN(s). In
such cases, only the line items using the –GA modifier are considered related to the ABN and must be covered charges, other ine items on the same claims may appear as covered or noncovered charges.