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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Mandatory ABNs

Circumstances in which the healthcare provider must give an ABN to the patient. 

The following provisions necessitate delivery of the ABN:

Services not considered reasonable and necessary (Most Common for PT and OT)

Violation of the prohibition on unsolicited telephone contacts

Medical equipment and supplies supplier number requirements not met

Medical equipment and/or supplies denied in advance

Custodial care

Hospice patient who is not terminally ill

Home health services requirements are not met – not confined to the home or no need for intermittent skilled nursing care

Personalized prevention plan services

When a noncontract supplier furnishes an item included in the Durable Medical Equipment, Prosthetic, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) for a Competitive Bidding Area (CBA)

When Medicare considers an item or service experimental (e.g., a “Research Use Only” or “Investigational Use Only” 

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