A. All of the above

B. 2 and 3

C. 1, 3, and 4

D. 1, 2, and 4

Answer:

C. 1, 3, and 4

The following statements are true:

1. An ABN (Advance Beneficiary Notice of Non-coverage) refers to a standardized form that explains to the patient why Medicare may deny a certain procedure.

3. Notifiers must insert an estimate that is within $100 or 25 percent of the actual costs, whichever is greater.

4. Once a beneficiary signs the ABN, it is his or her responsibility to pay for the service or procedure if Medicare does not provide coverage.

CMS requires providers to give their Medicare patients an ABN before they can bill them for charges not covered by Medicare. Not all non-Medicare payers recognize this form and instead may have a “hold harmless” clause in their contracts that only allows providers to bill patients for copays and/or deductibles.

According to Carol Buck of Buck’s Step-by-Step Medical Coding, 2020 Edition, there are four modifiers associated with Medicare’s ABN. They are -GA, -GX -GY, and -GZ.

  • -GA. Indicates an ABN form is on file, so the patient knows the item or service may be denied by Medicare.
  • -GX. Indicates it’s a non-covered charge, and Medicare will reject all claims with this modifier. Assignment is voluntary under payer  policy.
  • -GY. Indicates the item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
  • -GZ, Indicates the item or service is expected to be denied due to not being reasonable and necessary. This modifier is used when no ABN is signed by the beneficiary, and the provider is assuming cost liability.

The above modifiers should not be reported together, except when using -GX and -GY together to indicate the patient signed a voluntary ABN for a service excluded by Medicare.

A, B, and D are incorrect.

An ABN does not stand for Advanced Benefits Notification. (2). 

A picture of an ABN is posted below. More information about this form and instructions for filling it out can be found at CMS.gov.

 


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