ABN
Advance Beneficiary Notice of Non-Coverage (ABN)
What is an ABN?
Medicare requires an Advance Beneficiary Notice of Non-Coverage (ABN) for services that Medicare covers but, for a particular situation, likely won't be covered.
Medicare covers diagnostic hearing and balance exams that a doctor or advanced practice practitioner orders to determine if the patient needs medical treatment. An ABN is required for hearing tests that fall outside of that definition.
Covered: when the test is ordered to evaluate or manage a medical condition. Examples: sudden hearing loss, vertigo/dizziness, chronic otitis media, asymmetric hearing loss, pre- or post- surgical evalation.
Not-Covered: when the hearing test is not for medical treatment, but rather solely for: hearing aid evaluation, annual hearing test with no new complaints, no documented change in hearing, or patient-requested testing without a physician/APP evaluation of a new complaint.
Examples requiring an ABN:
✔ Hearing test for the purpose of prescribing, fitting, or changing hearing aids
✔ Hearing test at the request of a patient for a baseline hearing test
✔ Patient request for an annual hearing test with no changes or new complaints
✔ Routine ear cleaning without cerumen impaction
✔ Allergy testing requested by patient without symptoms
✔ Lesion removal without symptoms (cosmetic)
✔ Balloon sinuplasty when patient has not met criteria but elects to move forward
FAQs:
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Use this form when you do not anticipate a payor will cover the service. Examples include:
The patient does not meet the payor's medical necessity guidelines for a service but wants to have it anyway
A service that a payor considers experimental/investigational
For payors who allow it, an upgrade waiver for hearing devices text goes here
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No, it must be completed specifically for the services the patient is receiving today and cannot be a blanket form.
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No, the ABN is exclusive to Medicare patients. However, commercial payors also require patients to agree in advance to receiving a non-covered service. Some payors have their own forms. In the absence of a payor-required form, we recommend creating a "non-covered services" waiver for patients.
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No, Medicare requires the use of the official ABN form when an ABN is required.
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No. Since Medicare does not cover hearing aids, no ABNs are needed related to hearing aids.
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No. Since cosmetic procedures are statutorily excluded from Medicare, an ABN is not appropriate. However, if the procedures are functional in nature, but the patient does not fully meet MAC coverage criteria, consider issuing an ABN.
Claim Reporting Modifiers
▶️ Report ABN modifiers as follows:
GA
What it Means
Waiver of Liability Statement Issued as Required by Payer Policy
Used to Report
When to Use It
Billing/Payment Implications
A required ABN was issued and is on file
Covered procedure/service may not meet the carrier’s definition of medical necessity (e.g., LCD)
1) Bill Medicare, accept Medicare payment
Or
2) Obtain cash from patient and see if Medicare pays; if so, then refund Medicare
GX
Notice of Liability Issued, Voluntary Under Payer Policy
A voluntary ABN was issued for a service
When you want to issue a notice of non-coverage for services that are statutorily excluded such as cosmetic surgery. Medicare never covers the service.
Patient pays you cash, you bill Medicare and do not expect payment.
GY
Item or Service Statutorily Excluded or Does Not Meet the Definition of Any Medicare Benefit
An ABN was not issued because the item or service is statutorily excluded or does not meet the definition of any Medicare benefit
Medicare never covers the service but you want the denial from Medicare so you can bill the secondary payor.
Bill Medicare to get the denial. Submit the denial to the secondary payor for payment. If the secondary doesn’t pay, then you can balance bill patient (or refund patient if you obtained cash prior to service)
GZ
Item or Service Expected to be Denied as Not Reasonable and Necessary
An ABN was not issued for a service
Typically used when the patient has not signed an ABN in an emergent situation
Bill Medicare and appeal for payment.
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