Medicare ABN Information

Advanced Beneficiary Notice (ABN) Forms

Medical Necessity Verification Tool

Advanced Beneficiary Notice

National Coverage Determinations (NCD's) is a document for diagnostic laboratory testing stating The Centers for Medicare and Medicaid (CMS) policies with respect to circumstances under which laboratory test(s) will be considered reasonable and necessary, and not screening, for Medicare purposes. Regional Pathology Services accepts Medicare assignment and is not allowed to bill Medicare beneficiaries for the NCD tests listed below unless an ABN is executed by the provider that tells the beneficiary in advance of the service that they will be responsible for the payment of the test(s) if Medicare should deny payment.·

ABN’s should be executed when:

Tests(s) are deemed by the NCD policy as not medically necessary.
Screening test(s) that are part of a routine examination where the patient shows no signs nor symptoms of disease.
Test(s) that exceed the NCC frequency limits.
Test(s) that are considered experimental or investigational/not approved by FDA.

These policies are updated every three months, with revisions published between final publications. It is ideal to use the latest version of the NCD policies.

It is the policy of Regional Pathology Services and The Nebraska Medical Center to ensure that an appropriate Advanced Beneficiary Notice (ABN) is obtained from Medicare beneficiaries for laboratory tests prior to collection of the specimen(s) that are deemed to be not reasonable and necessary.

Effective January 1, 2005 all laboratory test(s) requests for Medicare patients that does not have a diagnosis that meets the NCD guidelines for medical necessity and do not have an ABN attached, will be billed directly to the clinic/office that initiates the test order. Testing that does not require an ABN will be billed to Medicare. Blanket or routine ABN forms are nt allowed by CMS. ABNs should be executed when non-payment is anticipated.

ABN Usage Overview

Obtain ABN if tests(s) may or does not meet medical necessity requirements.
Obtain ABN if test(s) may only be paid for a limited number of times (frequency limits).
Obtain ABN if test(s) used only on investigational purposes.
Patient request services that are not deemed medically reasonable by the provider.
Use form CMS-R-131.
Fill in patient's last, first name, and middle initial if applicable.
- List test(s) in the space provided.
- Mark the applicable reason Medicare may not pay.
- Fill in the estimated cost of the (test)s to the beneficiary.
"X" Option 1 or Option 2 or Option 3.
Date form.
Have beneficiary sign.
Attach original to the laboratory request form (requisition).
Retain the a copy for your records and give a copy to the beneficiary.
Note that the NCD for Blood Counts that includes a Complete Blood Count and all of the applicable components is an exclusionary policy, meaning it does not list the covered codes, only those expected to be denied.

Local Coverage Determinations (LCD’s) refers to the same types of exclusions as the NCD policies. Medical fiscal intermediaries or carriers have such exclusions in their policies. In addition to the NCD policies the Medicare billing contractor for Regional Pathology Services has enacted the following LCD policies.

LCD Policies

Cytogenetic Studies
Flow Cytometry
Free Prostate Specific Antigen (Free PSA)
Helicobacter Pylori Testing
Prostate Specific Antigen (PSA)
Vitamin D Testing

Search the Center for Medicare and Medicaid web site.

Go to: Medicare Coverage Database
Click on: Advanced Search
Check: Local
Choose: State
Enter cpt code range: 80000-83999
Go to the applicable LCD for cpt codes and diagnosis codes applicable to the individual LCD.