The Academy of Doctors of Audiology (ADA), the Academy of Rehabilitative Audiology (ARA), the American Academy of Audiology (AAA), and the American Speech-Language-Hearing Association (ASHA) developed the following frequently asked questions as a resource to assist members with practice and billing questions for the Advance Beneficiary Notice (ABN) for audiologists. This guidance is appropriate for fee-for-service Medicare Part B beneficiaries only.
See also: Additional Resources
The Advance Beneficiary Notice of Noncoverage (ABN) is a Medicare document that is used to notify Medicare beneficiaries of their potential financial responsibilities prior to the rendering of a service or the dispensing of an item. The current ABN form (CMS-R-131 effective March 2011) and its accompanying guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website.
As noted in the ABN directions, the following is to be included on the ABN form:
The typical reasons may include but are not limited to the following:
Medicare will only pay for services considered "reasonable and necessary" which includes audiology diagnostic services. Medicare will only pay for services considered "medically reasonable and necessary." As a result, medical necessity must be met to ensure Medicare coverage for audiology diagnostic services.
Program Memorandum AB-02-080 [PDF] states "diagnostic testing, including hearing and balance assessment services, performed by a qualified audiologist is paid for as 'other diagnostic tests' under §1861(s)(3) of the Social Security Act (the Act) when a physician orders testing to obtain information as part of his/her diagnostic evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem." Medical necessity includes the patient noting a change in one or more conditions, which may be new, or a change in a previous condition(s) such as hearing loss, tinnitus and/or dizziness. Information specifically related to the medical necessity of audiologic procedures can be found in the CMS Update to Audiology Policies [PDF].
Medicare contractors have Local Coverage Determination policies (LCDs) that are coverage guidelines developed by the contractor to provide rules either for determination of coverage in the absence of a National Coverage Determination policy (NCDs) or for further clarification of a NCD or LCD. Please go to the CMS Medicare Coverage Database to find information related to specific LCDs in your area. LCDs are not an inclusive list and may not address audiology and/or vestibular procedures. If an audiology/hearing/vestibular LCD is in effect, your Medicare contractor may define "medically necessary" as well as the appropriate codes that are reimbursed based on medical necessity. NCDs are established by Medicare and stipulate the conditions for a reimbursable procedure for a Medicare beneficiary. Currently, two NCDs relate to audiology and address cochlear implantation and tinnitus devices.
The provider may complete the provider applicable portion of the ABN form; however, the beneficiary must complete the portion of the form indicating their choice of how the services should be billed to Medicare.
The ABN alerts the patient of their fiscal responsibility for non-covered services and has two roles:
The use of the mandatory ABN allows the provider to notify the beneficiary that the item or service which is typically covered by Medicare may not be covered in this case. If Medicare denies payment for that item or service, the provider may collect payment directly from the beneficiary. This type of ABN must be completed before the item(s) or service(s) are provided.
Some common situations where the use of a mandatory ABN would be warranted:
Mandatory ABNs should never be used routinely (i.e., for every beneficiary or for the majority of beneficiaries). It should only be utilized when the specific need arises for its use for a particular patient procedure on a particular date of service. Issuing a mandatory ABN, or routinely using the -GA modifier for a service that is never covered, does not automatically transfer financial liability to the beneficiary, especially in the case of an improperly submitted claim.
If a mandatory ABN is completed and the beneficiary wants the claim submitted to Medicare for a coverage decision (i.e., they selected option 1 in section G), the provider should add the –GA modifier to the item(s) or service(s) on the CMS 1500 claim form that were listed on the ABN.
The voluntary ABN was the result of the merger of the old Notice of Exclusions from the Medicare Benefits (NEMB) and the ABN forms in 2008. This new ABN then replaced the Notice of Non Coverage document that previously existed. Voluntary use of an ABN is not required in order to collect payment from a Medicare beneficiary. Its use is solely for beneficiary notification, information, and transparency.
Some common situations where a voluntary ABN may be useful are:
The provider should add the –GY (item or service statutorily excluded or does not meet the definition of a Medicare benefit) and -GX (indicates that voluntary ABN has been issued) modifiers to the item(s) or service(s) that were listed on the ABN.
If the patient directs you to file the claim, then you must file a claim for a non-covered service with the GY and GX modifiers appended in box 24D of the CMS 1500 claim form.