When Should an Medicare ABN Be Given?

Mandatory ABN Uses

An ABN should be given when Medicare is expected to deny payment (entirely or in part) for the item or service because it is not reasonable and necessary under Medicare program standards.

Voluntary ABN Uses
ABNs are not required for care that is statutorily excluded. However, the ABN can be issued voluntarily in place of the NEMB.

Examples of Medicare program exclusions are:

• Personal comfort items.

• Self-administered drugs and biologicals (i.e., pills and other medications not administered by injections).

• Cosmetic surgery (unless required for prompt repair of accidental injury or for improvement of a malformed body member).

• Eye exams for the purpose of prescribing, fitting or changing eyeglasses or contact lenses in the absence of disease or injury to the eye.

• Routine immunizations (except influenza vaccine, pneumococcal vaccine and hepatitis B vaccine; these services have specific regulations regarding patient responsibility).

• Physicals, laboratory tests and X-rays performed for screening purposes (except screening mammograms, screening Pap smears and various other mandated screening services; these services have specific guidelines regarding patient responsibility and when an ABN should be obtained).

• X-rays and physical therapy provided by chiropractors.

• Hearing aids and hearing examinations.

• Routine dental services (i.e., care, treatment, filling, removal or replacement of teeth).

• Supportive devices for the feet.

• Routine foot care (i.e., cutting or trimming corns or calluses, unless inflamed or infected; routine hygiene or palliative care or trimming of nails).

• Custodial care.

• Services furnished or paid by government institutions.

• Services resulting from acts of war.

• Charges made to the Medicare program for services furnished by a physician or supplier to his immediate relatives or members of his household. The following relationships are included in the definition of immediate relative: husband and wife; natural parent, child and sibling; adopted child and adoptive parent, adopted sibling; stepparent, stepchild, stepbrother and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law and sister-in-law; grandparent and grandchild; and spouse of grandparent or grandchild. By definition, members of the household include those persons sharing a common abode with the physician as part of a single family unit, including those related by blood, marriage or adoption; domestic employees; and others who live together as part of a single family unit.

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