To secure payments and prevent audits, you must have your patients sign the correct version of the Medicare ABN form.

Don’t risk fines and face write-offs by submitting the wrong form — educate yourself on when a Medicare ABN is mandatory or voluntary to protect your practice against unpaid claims.

What is a Medicare ABN?

Medicare’s Advance Beneficiary Notice (ABN) of Noncoverage is a form that you must issue to your office patients when you believe that Medicare may not pay or cover a proposed treatment, service, or item.

According to CMS, an ABN “helps a Medicare Fee-For-Service beneficiary make an informed decision about items or services Medicare usually covers but may not pay because they are medically unnecessary.” A Medicare ABN form has two purposes:

1. Patient Education so the patient can make an informed decision about his care and financial liability.
2. Financial Liability whether the patient accepts or denies financial responsibility for the recommended services/items. If you fail to issue an ABN for a service that Medicare usually covers that a patient receives, and the service is denied, you are liable for the cost. Without a signed ABN, Medicare does not allow you to bill a patient for a service, and you must write off the amount. When you present a Medicare ABN form, the patient can choose whether to have the service and whether to accept financial responsibility as follows:

• Option 1: The patient agrees to the service/item, that you will bill Medicare, and if Medicare doesn’t pay, he or she will be financially responsible.
• Option 2: The patient agrees that you will not bill Medicare for the services/items. Instead, he or she will pay for them out-of-pocket.
• Option 3: The patient denies the services/items. This option also removes the patient’s ability to appeal to see if Medicare would pay for it.

What is a Mandatory Medicare ABN?

Medicare requires you to issue an ABN to a patient when you have reason to believe that a proposed treatment, service, or item that Medicare typically covers, won’t be covered in the patient’s situation. This is considered a mandatory ABN, and you would use this type in the following situations:

• Initiation of treatment: When you have information that Medicare may not reimburse you for a service that is typically covered prior to the start of you providing care, you are required to issue an ABN.
• Decrease in services: When a patient’s changing needs cause the provider to decrease the volume of the patient’s service, Medicare will usually consider the original, higher volume, to be no longer reasonable or medically necessary. If your patient wants to continue to receive the higher volume even if Medicare won’t fully cover, you must issue an ABN for the difference between what Medicare will pay and the higher volume the patient wants. Beware: Having a completed and signed ABN is the only way you are allowed to bill the patient for the additional amount due.
• Discontinuation of care: When the provider has determined that a patient no longer needs a service, but the patient disagrees and wants to continue, Medicare probably will not cover the service any longer. In these cases, you must issue an ABN so that you can collect from the patient directly.
• Lack of medical necessity: The service is not medically necessary such as the diagnosis code does not support medical necessity for the service.
• Frequency limitations exceeded: When a patient requests a service more often than determinations allows such as a retest of a lab test that Medicare allows only once per year.
• Screenings outside coverage areas: Issue a mandatory ABN when a patient requests a screening in an area not covered by policies such as a request for a telemedicine screening outside a rural coverage area.

What is a Voluntary Medicare ABN?

When you choose to issue an ABN even though it isn’t required by Medicare, you file a voluntary ABN. For example, you are not required to use an ABN for services that are not part of the Medicare program (statutorily excluded services) or with private payer patients, but you may choose to do so as a courtesy.

When you know services are not covered by Medicare, even though you aren’t required to issue a voluntary ABN, doing so allows you to bill the patient.

What are Medicare ABN Modifier Requirements?

There are so many different situations that can affect which ABN you should use. For example, do you know:

• If you’re required to provide ABN forms in multiple languages?
• How to identify which treatments aren’t covered by Medicare?
• How to apply ABN modifiers to avoid denials?
• What ABN form and modifier you should use if your patient refuses to get a referral for services?
• What a non-Medicare ABN is and when you should use one?

For answers to these questions plus step-by-step guidance on how to correctly determine whether you should use a mandatory or voluntary ABN form, join expert coder, Leonta (Lee) Williams, RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC, in her online training session.

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