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ABN Quick Reference Guide 

Advanced Beneficiary Notice (ABN) of Noncoverage

Federal law requires an audiologist to notify a Medicare beneficiary in advance, when the audiologist believes that Medicare will likely deny coverage in a particular instance because the item or service is not considered by Medicare to be medically reasonable and necessary. The mandatory ABN fulfills this notice requirement. The ABN allows the audiologist to shift financial liability to the beneficiary if the claim is submitted and Medicare denies the claim.

Mandatory ABN

The ABN is only deemed mandatory when an otherwise covered service will likely be denied by Medicare as not being medically reasonable or necessary.


Example
A national or local coverage determination indicates that a service does not meet the standard for medical necessity in a particular instance.

When a mandatory ABN is issued, the entire form must be completed and the beneficiary or their representative must sign the ABN.  (Please consult the instructions for the ABN written by CMS for complete and the most up-to date information and details).

Voluntary ABN

ABN's are not mandatory when an item or service is excluded (never covered) or does not otherwise meet the technical coverage criteria of the Medicare benefit.


Examples

  • Tests not ordered by a physician or NPP
  • Routine tests (no new signs or symptoms)
  • Hearing aids and hearing aid related services
  • Treatment services not covered by Medicare when provided by an audiologist
    (e.g. cerumen removal, canalith re-positioning).

Voluntary ABN's are optional, the entire form does not need to be completed and it does not need to be signed.

Modifiers Associated with ABN when Submitting the Claim to Medicare

GA—Item or service may not be covered, use when a mandatory ABN is issued.
GY—Item or service is never covered under Medicare benefit
GX—Use when a voluntary ABN issued. (Note, GX is an optional modifier and cannot be reported individually. GX maybe
          reported with GY but can never be reported with GA).
GZ—Item or service expected to be denied as not reasonable and necessary but ABN was not issued

Helpful References and Resources Related to the ABN

CMS Instructions and Form for ABN and ABN Manual

Choose the CMS R-131 zip file ink which contains the up to date ABN instructions and the ABN form in English and Spanish.  The ABN form is available in both PDF and DOC format.  The DOC format can be individualized for your practice according to CMS instructions. 

CMS Audiology Policies

CMS National Coverage Policies for Audiology Services

 Medicare Benefit Policy Manual, Chapters 15, Sections 80.3 and 80.31

CMS ABN Advance Notice of Non-Coverage (ABN) Policies

 Medicare Claims Processing Manual, Chapter 30, Section 50 

Articles and Items of Interest

 ABN Decision Matrix—A systematic approach for determining the correct use of the ABN for audiologists
Audiology Today, July/August 2012

 Audiology Organization’s ABN Q&A

 Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, Updated Manual Instructions
MLM Matters MM7821

The purpose of the information provided by the American Academy of Audiology Coding and Reimbursement Committee is to provide general information and educational guidance to audiologists. Action taken with respect to the information provided is an individual choice. The American Academy of Audiology hereby disclaims any responsibility for the consequences of any action(s) taken by any individual(s) as a result of using the information provided, and reader agrees not to take action against, or seek to hold, or hold liable, the American Academy of Audiology for the reader's use of the information provided. As used herein, the "American Academy of Audiology" shall be defined to include its directors, officers, employees, volunteers, members, and agents.

 Also of Interest