New ABN


There has been an update to the ABN.


Effective 1/1/21, the new ABN should be used.


The new ABN offers additional explanations, as well as considers those patients with QMB. QMB stands for Qualified Medicare Beneficiary Program. QMB is a program for patients who are enrolled in Medicare and Medicaid. These patients are not responsible for paying any deductibles, coinsurance or copays. In most states, Medicaid often pays any cost-sharing. But, patients should never be billed, so if your Medicaid does not pay any balances after Medicare, you must write it off.


You may find more information about QMB here:


https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/QMB

The updated ABN can be found here:


https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN

When billing Medicare for these services, certain modifiers should be used, depending on the situation, Below you will find a list of modifiers and the situations when they should be reported.


–GA Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case

  • Report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN, but you must have it available on request. The –GA modifier is used when both covered and noncovered services appear on an ABN-related claim.

–GX Notice of Liability Issued, Voluntary Under Payer Policy

  • Report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier combined with modifier –GY.

–GY Notice of Liability Not Issued, Not Required Under Payer Policy

  • Report that Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. You may use this modifier combined with modifier –GX.

–GZ Expect Item or Service Denied as Not Reasonable and Necessary

  • Report when you expect Medicare to deny payment of the item or service because it is medically unnecessary and you issued no ABN.

Remember, there are times when you do not need to use an ABN.

  1. Services you provide under Medicare Advantage (Part C) or the Medicare Prescription Drug Benefit (Part D).

  2. Services that are not a Medicare benefit or that Medicare never covers. For a list of Medicare non-covered items and services, see the Medicare Claims Processing Manual here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf#page=14

More information, see this PDF from the Medicare Learning Network:


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf


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