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What is an ABN? Medical Challenge

what is an ABN
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Medical Challenge

Question: Which of the following statements are true as they relate to an ABN?

  1. An ABN is a standardized form that tells patients why Medicare may deny a particular service or procedure.
  2. ABN stands for Advanced Benefits Notification. 
  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.  

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.

According to Carol Buck of Buck’s Step-by-Step Medical Coding, 2023 Edition, four modifiers are associated with Medicare’s ABN: -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. The assignment is voluntary under the 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 assumes 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.

Incorrect Answers

A, B, and D are incorrect.

Statement #2, “ABN stands for Advanced Benefits Notification,” is incorrect. This eliminates answers A, B, and D.

what is an ABN
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2 Comments

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