The ABN (CMS – R -131) is a notice given to Medicare beneficiaries to inform them that Medicare will most likely deny the care that they are about to receive. The ABN must be delivered in advance to give the beneficiary time to consider the options and make an informed choice.
Additional Resources on this Topic:
- American Academy of Audiology’s Advanced Beneficiary Notice of Non-Coverage (ABN) Quick Reference Guide
- CMS Instructions and Form for ABN and ABN Manual
Q: May audiologists perform services on a Medicare patient without a physician referral if the patient agrees to pay for the service out-of-pocket?
A: To be covered by Medicare, federal law requires a licensed practitioner’s order for all diagnostic tests. An audiologist may perform diagnostic audiology tests on a Medicare patient without a physician referral. This procedure would not be covered by Medicare and is the responsibility of the patient. If a claim needs to be submitted to Medicare the -GY modifier must be appended to the CPT code, which alerts Medicare that the service is not eligible for coverage. Many other third-party payers reimburse audiologists for services without a physician’s order.
Q: Does routine audiologic testing require completion of an ABN given that audiologic testing is covered by Medicare when medically necessary?
A: ABNs are not required for services that are statutorily excluded or do not otherwise meet the coverage requirements of the Medicare. Examples of statutorily excluded services include hearing aids and routine hearing exams, diagnostic tests done without physician order. Otherwise not covered would include services not covered by Medicare when performed by an audiologist. In all of these cases, issuing an ABN is voluntary.
Q: Are there times when an ABN should not be used?
A: Mandatory ABN’s should only be issued when a procedure that is typically covered by Medicare is not covered in this specific instance. (Procedures requiring a mandatory ABN need to be reported with the GA modifier). The provider should have an idea whether the service is typically covered. It should be noted that instances of needing to use a mandatory ABN’s are not that common for audiology.
Voluntary ABN’s on the other hand are more common for audiology because the current Medicare benefit for audiology services is very narrowly defined. Voluntary ABN’s may be issued for any procedure that is never covered by Medicare. If a claim is submitted to Medicare when a voluntary ABN is given, the GY and GX modifiers need to be reported. Please visit the Academy’s ABN reference page for more specific information on the types of ABNs and the applicable modifiers.
Q: Should an ABN be used for private insurers?
A: The ABN (CMS 131-R) form should only be used for Part B Medicare services.
Q: What information should be included in an ABN?
A: The mandatory ABN requires that the entire form be completed, dated and signed. The voluntary ABN does not have these requirements. For more specific information, please refer to the ABN instructions on the CMS website. You can find the link to these instructions in the resource links above.
Revision Date 12/3/2012