Is an ABN Mandatory or Voluntary? Here are 4 Clues to Decide

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Is an ABN Mandatory or Voluntary? Here are 4 Clues to Decide

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Medicare ABN Mandatory

The Medicare Advance Beneficiary Notice (ABN) form is only one page long, but accurately completing the process can be as tedious as waiting for the repair man to show up. And it’s really critical that you take the time to get each step right, or you’ll be faced with increased write-offs and could even land on Medicare’s audit list.

The first stage in compliant form usage is correctly identifying when to complete it. There are times when the Medicare ABN’s mandatory, and times that it’s Voluntary. But be careful not to take the easy way out and give it to every patient “just in case.” CMS prohibits using the ABN as a blanket form. Issuing the ABN form only when it’s Mandatory will save you valuable time and ensure you don’t end up footing the bill for services that are the patient’s responsibility. Medicare ABN Mandatory.

You can more confidently pinpoint when is it imperative to complete a Medicare ABN Mandatory form and when can you take a pass using four clues.

Consider If Form Educates or Creates Monetary Obligation

To determine whether an ABN is Mandatory or Voluntary, you must be clear on the form’s purpose. The ABN has two purposes:

  • Patient Education: The ABN allows the patient to make an informed decision about their care.
  • Financial Liability: The way you complete the ABN determines whether or not the patient accepts financial responsibility for the services included on the form.

Determine Statutorily Excluded or Non-Covered

Knowing the difference between these two terms will help you decide whether the ABN is Mandatory or Voluntary. This is because CMS requires you to issue an ABN if you have reason to believe that a service that Medicare typically covers would not be covered in the patient’s specific situation. That is, the services don’t meet coverage criteria for some reason. In that case, the ABN is Mandatory.

In contrast, statutorily excluded services (e.g, 99397, a preventive medicine exam) are never covered by Medicare. They are excluded by statute and not part of the Medicare program. Because these services are never covered, you are not required to issue an ABN to the patient. It is Voluntary. Of course, you may do so as a courtesy to the patient, but you won’t be noncompliant if you don’t.

Recognize Mandatory ABN Trigger Events

CMS points to three specific circumstances that should clue you in to determine whether the ABN is Mandatory or Voluntary:

  • Start of Treatment: If you have reason to believe Medicare may not pay for a service, you should issue an ABN prior to providing the service.
  • Decrease in Services: When a patient’s needs change, and a provider decreases the volume or service of an item (therapy sessions, for example), Medicare will typically not pay for the higher level of service. If the patient wants to continue receiving the service despite it exceeding frequency limits, you should issue an ABN.
  • Termination of Care: This is similar to when a provider decreases services. If a provider determines that a services is no longer medically necessary, but the patient wants to continue on, you should issue an ABN. One example would be if a patient received hospice services, but their prognosis changed and they are no longer terminal, but want to continue with hospice.

Check Patient Coverage for Secondary Payer

If a patient has secondary coverage, that payer may pay for services that Medicare doesn’t cover. Sometimes, the secondary payer requires a denial from Medicare for those services first. If you don’t issue an ABN to the patient, and both Medicare and the secondary payer deny the claim, you’ll be stuck writing off the entire amount. But if you do issue an ABN, you can bill the patient should both Medicare and the secondary payer deny the claim. Medicare ABN Mandatory.

For more answers to common Medicare ABN Mandatory or Voluntary how-to questions, there’s help from expert coder, Leonta (Lee) Williams, RHIA, CCS, CCDS, CPC, CPCO, CEMC, CHONC, CRC. During her online training, “ABN Mandatory vs Voluntary: Avoid Common Errors & Costly Audits,” you will be provided with step-by-step guidance on how to correctly determine the situations wherein a Voluntary or Mandatory ABN form should be used.


ABN Form Training Resources 

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ABN Mandatory vs Voluntary: Avoid Common Errors & Costly Audits
Master Advance Beneficiary Notice Requirements and Get PAID
Mandatory vs. Voluntary: When is an ABN Necessary?
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Meet Your Writer

Leonta Williams

RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC Director of Coding Leonta (Lee) Williams is currently the Director of Coding at a large physician organization in the southeast.  Lee has over 15 years of experience working in both the outpatient and inpatient setting.  Some of her professional roles have included coder, auditor, practice manager, educator, and trainer. Lee has presented at national healthcare conferences, private healthcare training organizations, and has frequently contributed articles to healthcare publications.  She currently serves on a number of Boards including Georgia Health Information Management Association (GHIMA) and the American Academy of Professional Coders (AAPC).  Lee has a B.S. in Health Information Management and an MBA with concentration in Healthcare Administration.

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