November 23, 2010 News

Medicare Form Addresses Noncoverage of Services

Audiologists and speech-language pathologists who are enrolled as Medicare providers may recommend services that, for any number of reasons, are not usually covered by Medicare. These providers should use the Advance Beneficiary Notice of Noncoverage (ABN), a written notice signed by the patient indicating the patient understands that Medicare is not likely to provide coverage.

In some situations, the use of the form is voluntary; in other situations, use of the form is mandatory.

Voluntary Use 

It may be useful for providers—and beneficiaries may find it helpful—to use the form in some situations that do not require it:

  • The services are excluded from coverage by Medicare statute (e.g., hearing aids and hearing aid evaluations).
  • The services would be covered, but specific coverage prerequisites have not been met (e.g., lack of physician certification of the plan of care for speech-language services or physician order for hearing evaluation).

In these cases, the patient may ask the provider to submit a claim even though the provider has explained that the service will not be covered. The signed ABN and associated modifier inserted on the claim form (see description below) inform the Medicare administrative contractor (MAC) that the provider is not attempting to obtain Medicare payment for a service that does not qualify for coverage. The patient may want the claim submitted because the patient has private health insurance that will reimburse for services only if there is evidence that Medicare denied them.

Mandatory Use 

There are situations in which it is mandatory for the provider (facility or practitioner) to have the beneficiary/representative sign an ABN indicating that the beneficiary understands the services will not be covered. The situations most relevant to audiology and speech-language services include the following:

  • The care is not reasonable and necessary (i.e., functional progress is not anticipated to improve significantly in a generally predictable period of time).
  • The claim is for medical equipment or supplies (individual or group practices are usually not suppliers).

Completing the ABN

The provider must supply information in the block at the top of the form indicating "Reason Medicare May Not Pay." That information (e.g., "no physician referral" or "significant functional progress is not anticipated") may affect the beneficiary's decision whether or not to receive the treatment.

The practitioner must review the ABN verbally with the beneficiary or representative and answer any questions before the patient or representative signs the form. The patient must receive the form sufficiently in advance to have time to consider the options and make an informed choice. The beneficiary indicates his or her choice by selecting only one of the following options (taken verbatim from the form):

  • OPTION 1: I want the [description of service] listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
  • OPTION 2: I want the service listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
  • OPTION 3: I don't want the service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

CPT Modifiers

If the beneficiary chooses the first option (requesting that the provider bill Medicare), the provider must include a billing modifier on the claim form related to the ABN. The modifiers are inserted immediately after the CPT code. Liability rests with the provider unless a modifier is used to assign liability to the patient.

  • GY:  The item or service billed is statutorily excluded or does not meet the definition of any Medicare benefit.
  • GZ: The service is expected to be denied as not reasonable and necessary.
  • GX: The patient signs a voluntary (not required) ABN. May be used in combination with modifier GY or used separately.
  • GA: Covered and non-covered services appear on the same claim form.

Additional Information 

Providers should be aware of some additional information regarding the use of ABNs:

  • Routine ABNs are invalid—that is, providers may not give ABNs to beneficiaries when there is no specific reason to believe Medicare will not pay.
  • The provider keeps the original form; the beneficiary is given a copy.
  • A copy need not be submitted to Medicare.
  • If the beneficiary changes his or her mind, the
    provider should ask the beneficiary to annotate, sign, and date the original ABN.
  • The ABN can remain effective for up to one year.

Therapy Cap

If a Medicare beneficiary has exceeded his or her annual maximum allowed therapy services, but has met conditions of the exceptions process (i.e., services are documented as medically necessary), an ABN is not applicable because services are covered. If, however, the beneficiary has not met the exception criteria and still wants to receive services, the provider should have the beneficiary complete and sign the ABN to establish the beneficiary's financial responsibility for the services.

If Congress does not extend the therapy cap exceptions process, providers should use the "GY" modifier on claims that exceed the cap because the services would be excluded from Medicare coverage.

The ABN form (CMS-R-131) can be downloaded at Centers for Medicare and Medicaid's website. Medicare policies governing ABNs are in Chapter 1 of the Claims Processing Manual, Parts 50 and 60, available at online at CMS's website [PDF, 1.5MB] as well.  

Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org.

cite as: Kander, M. (2010, November 23). Medicare Form Addresses Noncoverage of Services. The ASHA Leader.

  

Advertise With UsAdvertisement