CMS Pub. 100-04, ch. 1, § 60.4.1

The billing instructions in this subsection apply to payment condition 2.

If an ABN is given, the billing procedures in this subsection must be used, rather than

traditional demand billing. Using an ABN is frequently required, and is also allowed on

a voluntarily basis when a provider sees fit. It is used more often than traditional demand

billing.

Claim level coding

When a provider determines the beneficiary’s services for certain benefits should be

terminated, the provider must follow the ED instruction requirements located at section

150.3 below. If the beneficiary chooses to receive non-covered services after the date the

provider believes covered services are terminated, the provider must also issue an ABN

to the beneficiary.

In using the ABN, beneficiaries select only one option on the ABN notice prior to billing,

after they have been told that the provider anticipates Medicare will not cover a service.

Claims, other than HHPPS claims, billed in association with an ABN never use condition

code 20 or 21, and will be returned to providers if received with those codes. Instead, the

claims:

• Must use occurrence code 32 to signify all services on the claim are associated

with one particular ABN given on a specific date, unless the use of modifiers

makes clear that not every line on the claim is linked to the ABN;

• Must provide the date the ABN was signed by the beneficiary in association with

the occurrence code;

• Must use occurrence code 32 and the accompanying date multiple times if more

than one ABN is tied to a single claim for services that must be bundled/billed on

the same claim;

• Must submit all ABN-related services as covered charges (note –GA modifier

exception, below); and

• Must complete all the same basic required claim elements as comparable claims

for covered services.

Providers should be aware CMS may require suspension of any claims using occurrence

code 32 for medical review of covered charges associated with an ABN.

If claims using occurrence code 32 remain covered, they will be paid, RTP’ed, rejected or

denied in accordance with other instructions/edits applied in processing. Denials made

through automated medical review of service submitted as covered are still permitted

after medical review, and the Medicare contractor will determine if additional

documentation requests or manual development of these services are warranted. For all

denials of services associated with the ABN, the beneficiary will be liable.

Line level coding

The –GA modifier is used when provider must bill some services which are related and

some which are not related to a ABN on the same claim. The –GA modifier is used when

both covered and non-covered service appear on an ABN-related claim. Occurrence code

32 must still be used on claims using the –GA modifier, so that these services can be

linked to specific ABN(s). In such cases, only the line items using the –GA modifier are

considered related to the ABN and must be covered charges, other line items on the same

claims may appear as covered or non-covered charges.