Advance Beneficiary Notices
Wisconsin Health Information
Management Association
September 13, 2002
Presented by:
Richard Donkle, CPA
Rural Wisconsin Health Cooperative
Advance Beneficiary Notices
(ABNs)

Advise Medicare beneficiaries
 Issued before items or services are furnished
 Issued when Medicare is likely to deny payment
Advance Beneficiary Notices
(ABNs)
New ABNs
 CMS published in June 2002
 CMS-R-131
 General Use (ABN-G)
 Laboratory Tests (ABN-L)
Advance Beneficiary Notices
(ABNs)
New ABNs (continued)
 May not be modified
 Contain customizable boxes
Advance Beneficiary Notices
(ABNs)
ABNs are issued when Medicare probably or
certainly will not pay for an item or service
on the basis of one of the following
statutory exclusions:

Section 1862(a)(1) of the Act
 Section 1834(a)(17)(B) of the Act
 Section 1834(j)(1) of the Act
 Section 1834(a)(15) of the Act
Advance Beneficiary Notices
(ABNs)
ABNs are issued when Medicare probably or
certainly will not pay for an item or service
on the basis of one of the following
statutory exclusions (continued):

Section 1862(a)(9) of the Act
 Section 1879(g)(1) of the Act
 Section 1879(g)(2) of the Act
Advance Beneficiary Notices
(ABNs)
Section 1862(a)(1), lack of medical necessity,
exclusions include:
 Custodial Care
 Mammography
 Pap smear
 Pelvic exam
 Glaucoma
 Prostate cancer
 Colorectal cancer screening tests
Advance Beneficiary Notices
(ABNs)
Section 1834(a)(17)(B) addresses violation of
the prohibition on unsolicited telephone
contacts for medical equipment and supplies
Advance Beneficiary Notices
(ABNs)
Section 1834(j)(1) addresses situations where
medical equipment and supplies suppler
number requirements are not met
Advance Beneficiary Notices
(ABNs)
Section 1834(a)(15) addresses situations
where medical equipment and/or supplies
are denied in advance
Advance Beneficiary Notices
(ABNs)
Section 1862(a)(9) addresses custodial care
Section 1879(g)(1) concerns homebound and
intermittent denials for home health care
Section 1879(g)(2) addresses items or services
provided to a hospice patient who is not terminally
ill
Advance Beneficiary Notices
(ABNs)
Use of Condition Codes (Part A):
 21 - Item or service is non-covered, but a denial is
sought in order to bill other insurance (ABN not
required)
 20 – Used in a demand bill situation, when an
ABN has been issued, but beneficiary still wants
Medicare billed
Advance Beneficiary Notices
(ABNs)
Use of Modifiers (Part B):
 GA - ABN on file
 GZ - Item or service expected to be denied as not
reasonable and necessary (No signed ABN on file)
 GY - Item or service statutorily excluded or does
not meet the definition of any Medicare benefit
Advance Beneficiary Notices
(ABNs)
ABNs are not necessary for specifically
excluded items or services.
Excluded items include:
 Personal comfort items
 Most shots (vaccinations)
 Hearing aids and hearing examinations
Advance Beneficiary Notices
(ABNs)
Excluded items include (continued):
 Most outpatient prescription drugs
 Orthopedic shoes and foot supports (orthotics)
 Health care received outside of the US
 Services required as a result of war
 Services paid for by a government entity that is
not Medicare
Advance Beneficiary Notices
(ABNs)
Excluded items include (continued):
 Services for which the patient has no obligation to
pay
 Home health services furnished under a plan of
care, if the agency does not submit the claim
 Items and services excluded under the Assisted
Suicide Funding Restriction Act of 1997
Advance Beneficiary Notices
(ABNs)
Excluded items include (continued):
 Items or services furnished in a competitive
acquisition area by any entity that does not have a
contract with the Department of Health and
Human Services (except in a case of urgent need)
 Physicians’ services performed by a physician
assistant, midwife, psychologist, or nurse
anesthetist, when furnished to an inpatient, unless
they are furnished under arrangements by the
hospital
Advance Beneficiary Notices
(ABNs)
Excluded items include (continued):
 Items and services furnished to an individual who
is a resident of a SNF, or of a part of a facility that
includes a SNF, unless they are furnished under
arrangements by the SNF
 Services of an assistant at surgery without prior
approval from the peer review organization
Advance Beneficiary Notices
(ABNs)
Excluded items include (continued):
 Outpatient occupational and physical therapy
services furnished incident to a physicians’
services
 Routine physicals and most tests for screening
 Routine eye care, eyeglasses and examinations
 Cosmetic surgery
Advance Beneficiary Notices
(ABNs)
Excluded items include (continued):
 Dental care and dentures (in most cases)
 Routine foot care and flat foot care
 Services by immediate relatives
 Services under a physicians’ private contract
Advance Beneficiary Notices
(ABNs)
Examples of appropriate uses:
 Magnetic Resonance Angiography (MRA) to rule
out Renal Artery Stenosis – this is not a covered
indication for MRA per Coverage Issues Manual
(CIM) 50-14
 Hyperbaric Oxygen (HBO) treatments for a nonhealing venous stasis ulcer – this is not a covered
indication for HBO per CIM 35-10
Advance Beneficiary Notices
(ABNs)
Examples of appropriate uses (continued):
 Screening Mammography less than one year since
the last
 An experimental procedure, eg. Vagal Nerve
Stimulation (VNS) for Refractory Depression
 An item or service which is not reasonable &
necessary per a Local Medical Review Policy
(LMRP), e.g. IV levocarnitine given to a dialysis
patient (see UGS LMRP INJ-101)
Advance Beneficiary Notices
(ABNs)
Examples of inappropriate or unnecessary use:
 ER patient prior to medical screening exam
 Any patient “under duress”
 Excluded routine screening tests, e.g. cholesterol
testing without symptoms or history of
hypercholesterolemia
Advance Beneficiary Notices
(ABNs)
Examples of inappropriate or unnecessary use
(continued):
 Cosmetic surgery
 Hearing aids
 Tooth extraction
Advance Beneficiary Notices
(ABNs)
For additional information go to:
http://www.cms.gov/medicare/bni/
Advance Beneficiary Notices
Wisconsin Health Information
Management Association
September 13, 2002
Presented by:
Richard Donkle, CPA
Rural Wisconsin Health Cooperative