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January 25, 2018

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Medical Coding News Archives

CMS Mandates Strict Review of ABNs

January 10, 2011:

Contractors are instructed to determine the “face validity” (face-value merit) of the ABN if the claim is determined not to be reasonable and necessary under Medicare coverage guidelines.

An advance beneficiary notice (ABN) is a written notice that a provider completes and gives to a Medicare patient to communicate that a service or procedure may not be covered by Medicare. The provider should provide this document to the patient before performing the service. The patient is then aware that he or she may be responsible for payment and is able to make an informed consumer decision as to whether to receive the service/procedure.

Under these face-validity reviews included in the CMR process, the contractors will be examining the ABNs for appropriate application, meaning they were provided at the appropriate time and date. The purpose of the ABN is to inform the Medicare patient beforehand that Medicare may not cover the item or service; therefore, it is important that the ABN be completed before the service is rendered. This means that the patient fully understands the potential financial liability associated with the service, which can make collecting reimbursement from the patient significantly easier.

The ABN must specify the nature of the service and a legitimate reason that the provider anticipates or expects a Medicare denial. ABN standards are not satisfied by generic statements, signed by the beneficiary, indicating that the patient agrees to pay for the service should Medicare deny payment.

If an appropriately completed ABN is not issued to and signed by the patient, the provider is unable to bill the patient for any services not deemed reasonable and necessary under Medicare guidelines.

Deborah C. Hall
Clinical/Technical Editor


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