Does a beneficiary need to sign an Advance Beneficiary of Noncoverage (ABN) for every visit?
Answer:
Notifiers are required to issue ABNs when an item or service is expected to be denied based on one of the provisions in the Medicare Claims Processing Manual Chapter 30 §50.5. This may occur at any one of three points during a course of treatment which are initiation, reduction, and termination, also known as ‘triggering events.’
Initiations
An initiation is the beginning of a new patient encounter, start of a plan of care, or beginning of treatment. If a notifier believes that certain otherwise covered items or services will be non-covered (e.g., not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care.
Example: Mrs. S. asks her physician for an EKG because her sister was recently diagnosed with atrial fibrillation. Mrs. S. has no diagnosis that warrants medical necessity of an EKG but insists on having an EKG even if she has to pay out of pocket for it. The physician’s office personnel issue an ABN to Mrs. S. before the EKG is done.
Reductions
A reduction occurs when there is a decrease in a component of care (i.e., frequency, duration, etc.). The ABN is not issued every time an item or service is reduced. But, if a reduction occurs and the beneficiary wants to receive care that is no longer considered medically reasonable and necessary, the ABN must be issued prior to delivery of this non-covered care.
Example: Mr. T, is receiving outpatient physical therapy five days a week, and after meeting several goals, therapy is reduced to three days per week. Mr. T wants to achieve a higher level of proficiency in performing goal related activities and wants to continue with therapy five days a week. He is willing to take financial responsibility for the costs of the two days of therapy per week that are no longer medically reasonable and necessary. An ABN would be issued prior to providing the additional days of therapy weekly.
Terminations
A termination is the discontinuation of certain items or services. The ABN is only issued at termination if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary.
Example: Ms. X has been receiving covered outpatient speech therapy services, has met her treatment goals, and has been given speech exercises to do at home that do not require therapist intervention. Ms. X wants her speech therapist to continue to work with her even though continued therapy is not medically reasonable or necessary. Ms. X is issued an ABN prior to her speech therapist resuming therapy that is no longer considered medically reasonable and necessary.
Period of Effectiveness/ Repetitive or Continuous Noncovered Care
An ABN can remain effective for up to one year. Notifiers may give a beneficiary a single ABN describing an extended or repetitive course of noncovered treatment provided that the ABN lists all items and services that the notifier believes Medicare will not cover. If applicable, the ABN must also specify the duration of the period of treatment. If there is any change in care from what is described on the ABN within the one-year period, a new ABN must be given. If during the course of treatment additional noncovered items or services are needed, the notifier must give the beneficiary another ABN. The limit for use of a single ABN for an extended course of treatment is one year. A new ABN is required when the specified treatment extends beyond one year.
If a beneficiary is receiving repetitive non-covered care, but the provider or supplier failed to issue an ABN before the first or the first few episodes of care were provided, the ABN may be issued at any time during the course of treatment. However, if the ABN is issued after repetitive treatment has been initiated; the ABN cannot be retroactively dated or used to shift liability to the beneficiary for care that had been provided before ABN issuance.
ADVANCED BENEFICIARY NOTIFICATION
Medicare screening services are limited to a specific frequency (e.g., once every 2 years, once every year). A physician may not know whether a patient is eligible for this service in a given year. If she is not eligible, the service will be denied. Therefore, the physician should ask the patient to sign an advance beneficiary notice of noncoverage (ABN) using the form provided by Medicare. For more information on Medicare’s ABN form, visit http://www.cms.hhs.gov/BNI/02_ABN.asp. Claims for
Medicare patients should be submitted with the appropriate HCPCS modifier.
• GA modifier indicates that an ABN form has been signed.
• GZ modifier indicates that an ABN form has not been signed. (Item or service expected to be denied as not reasonable and necessary)
• GY modifier indicates that the service provided is not a covered Medicare benefit. The service is being reported to Medicare in order to receive a denial.
Using the appropriate modifier ensures that the patient will receive the correct information on her Explanation of Benefits (EOB). For example, when a service is reported with a GY modifier, the EOB will state that it is not covered and therefore is the patient’s responsibility.
