ABN-1500 form Billing Examples

Standard ABN: (waiver of liability)
Assigned claim. (Use same format for Non-assigned but collect up front)
Beneficiary does not qualify for medical necessity reasons.
Affirmative ABN is given with explanation of why Medicare may not pay. 
Patient can be billed up to Medicare allowable “after” claim has denied. 

Example:

E1390GA     Patient does not qualify under Medicare guidelines.

Free Upgrade:
When supplier chooses to lower costs by maintaining an inventory of only one type of product that can meet all of his needs within that product line. 
** NO ABN should be obtained** (This could come back and haunt us all.)

Example:
K0001RRKHGL for code and modifiers
In block 19 you would state what base was actually provided. ( Quickie Breezy 510 high strength light weight w/c for physician ordered standard w/c K0001 or light weight K0003 etc. ) 

Upgrade with ABN:
Physician ordered and signed CMN/order for standard item.
Patient requests deluxe item and agrees to be responsible for the difference.
No order/CMN is needed for upgraded item.

Make sure ABN is completed and patient fully understands what he is responsible for and be exact. ** see examples of forms on web site or call Peggy.**

Example: 
1st line of 1500 form will be the upgraded item with a GA modifier.
K0004RRKHGA
2nd line of 1500 form will be the actual item the physician ordered with GK modifier.
K0001RRKHGK
** Patient would pay the difference of your charge for the standard item and your charge for the upgraded item “plus” 20% of the Medicare allowable of the standard item and any deductibles not met. 

Upgrade without ABN: (Under what circumstance would a supplier choose to do this?) 
Physician ordered and signed CMN/order for a standard or generic item.
Patient requests a deluxe item and refuses or does not accept responsibility.
No order/CMN is needed for upgraded item.
Patient responsible for ONLY 20% of standard item.

Example:
1st line of 1500 form will be the upgraded item with GZ modifier.
K0004RRKHGZ
2nd line of 1500 form will be the standard item with GK modifier. 
K0001RRKHGK

Upgrade with ABN within the same HCPCs Code

Physician has ordered and signed a CMN/order for a standard or generic item.
Patient requests a brand specific item and agrees to be responsible for the difference.
** The upgraded item must still meet needs as outlined in the criteria for the specific item.**

Example: POV
E1230NUGA (deluxe 4 wheeled scooter that will fit in patients’ home)
E1230NUGK

NOTE: ABNS are to be used for patient choice.
Has to be suitable within the range of codes. 
ie: Can not be used to upgrade from a walker to w/c. - manual w/c to power etc. 

Can collect the money up front except when just using as Medical Necessity denial. 
Upgraded accessories would be billed the same way with same modifiers. 

Peggy Walker RN
Director of Member Education
US Rehab
800-401-3643