An ABN Doesn’t Allow Reimbursement for Bundled Procedures/Services

An ABN Doesn’t Allow Reimbursement for Bundled Procedures/Services

You should present Medicare patients with an Advanced Beneficiary Notice (ABN) only if the provider believes that Medicare may deny an otherwise covered item or service. If the patient is not given this advanced notice, providers may not shift financial liability for such items or services to beneficiaries should a claim for such items or services be denied by Medicare. A sample ABN (Form CMS-R-131, effective March 1, 2009), along with complete instructions for its use, may be found in the Chapter 30, Section 50 of the Medicare Claims Processing Manual. The same instruction and sample form may be found in CMS Transmittal 1587, CR 6136.

Never employ an ABN to seek separate payment for bundled services, or to bill Medicare beneficiaries for Medicare claims denied based on National Correct Coding Initiative (NCCI) edits. The “Introduction for National Correct Coding Initiative Policy Manual for Medicare Services” specifies:

Since these denials are based on incorrect coding rather than medical necessity, the provider cannot utilize an “Advanced Beneficiary Notice” (ABN) form to seek payment from a Medicare beneficiary. Furthermore, since the denials are based on incorrect coding rather than a legislated Medicare benefit exclusion, the provider cannot seek payment from the beneficiary with or without a “Notice of Exclusions from Medicare Benefits” (NEMB) form.

When properly using an ABN for services that Medicare may not cover, be sure to use the appropriate modifier on claim submission: GY for statutorily excluded services; GZ for services not reasonable and necessary without an ABN on file; and GA for services not reasonable and necessary with an ABN on file.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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