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To be sure, navigating the Medicare system and keeping up with changing rules and new forms and instructions can be time consuming and difficult!

Mandatory uses for the ABN

 The ABN instructions for mandatory uses of the ABN lists several scenarios or items for which the provision of the ABN form is required.  The first on the list is “item or service not reasonable and necessary”.    If the service is a covered Medicare benefit but is simply not covered for your patient’s current condition per a National or Local Coverage Determination, then the service is “not reasonable and necessary” per Medicare and the clinic is required to provide the ABN to the patient.

Voluntary ABN

 ABNs are not required for care that is either statutorily excluded from coverage under Medicare (i.e. care that is never covered).  However, the ABN can be issued voluntarily in these situations and we strongly encourage our clients to do so in order to maintain good patient relations and avoid misunderstandings regarding patient balances.

Specific examples

 An example of an item or service that is statutorily excluded from Medicare coverage, and thus does not meet the definition of any covered benefit, is hot/cold packs.  Providing hot or cold pack treatment to a patient would not be a service for which an ABN is mandatory.

 An example of a service that is not covered by Medicare, but does require an ABN, would be in the case of a Vitamin B-12 injection.  Many patients receive these injections for fatigue and general malaise.  While the injection is a covered Medicare benefit for certain conditions, it is not considered “reasonable and necessary” for the treatment of fatigue.  In this scenario, an ABN is required.

 Are you required to bill Medicare for this service? 

That depends on the patient.  The ABN form lists 3 options for the patient to choose from.  The patient may choose for the clinic to bill Medicare in Option 1.  If the patient chooses Option 1, then the clinic must bill Medicare for the services, even if the patient pays out of pocket for the service.  

 Another good reason to bill Medicare for non-covered services (be sure to append the GA modifier when you have a signed ABN) is to generate a denial indicating patient responsibility.  In these cases, patients with secondary coverage can often have these items not covered by Medicare, covered and paid by their secondary plan.

 A great Q &A document released from a Medicare webinar outlining the proper use of the ABN in a variety of scenarios can be found at:   http://www.medicarenhic.com/providers/seminars/abn-lcdqa_webinar0508.pdf

 HRS regularly consults with its providers and their support staff regarding the proper use of the ABN in their clinics.  If we may be of assistance to your clinic, please feel free to give us a call at 888-211-1118.