CODING AND REIMBURSEMENT | Advanced Beneficiary Notice of Noncoverage Use: Mandatory or Voluntary?

By Kristiina Huckabay and Kari Morgenstein

This article is a part of the March/April 2018, Volume 30, Number 2, Audiology Today issue.

Understanding the correct use of the Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 is important to ensure billing compliance for traditional Medicare (Part B). Audiologists may face challenges determining when Medicare covers a service and when an ABN is required. Federal law requires that providers, including audiologists, must notify a Medicare beneficiary in advance when a service that Medicare typically covers is likely to be denied and/or when the item or service is not considered by Medicare to be medically reasonable and necessary. The ABN meets this requirement. To better understand when an ABN should be used, let’s take a closer look at how Medicare identifies covered services.

In the simplest terms, to be reimbursed by Medicare for covered audiology services, the audiologist must have the following:

1. Documented medical necessity *
2. A physician or a non-physician practitioner’s order for the audiology evaluation

*Medically necessary hearing evaluations include, but are not limited, to the following: evaluation to determine the cause of hearing loss, tinnitus or balance disorders; changes in hearing, tinnitus or balance; diagnostic testing before and periodically after cochlear implantation; analysis and programming of cochlear or brainstem implants; audiologic re-evaluation following medical/surgical treatment; failure of hearing screening (Centers for Medicare and Medicaid Services).

If both conditions have not been satisfied, the audiologist will need to consider the specific scenario to determine if a mandatory ABN is required. Mandatory ABNs are required when the service performed is typically a covered service under Medicare, though in the particular case not all requirements for coverage have been obtained.