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.
The ABN is only deemed mandatory when an otherwise covered service will likely be denied by Medicare as not being medically reasonable or necessary.
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).
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.
- 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
CMS ABN Advance Notice of Non-Coverage (ABN) Policies
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
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