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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. 

When an item or service is not reasonable and necessary under Medicare Program standards. Common reasons Medicare denies an item or service as not medically reasonable and necessary include care that is:

  • Experimental and investigational or considered “research only”
  • Not indicated for diagnosis or treatment in this case
  • Not considered safe and effective
  • More than the number of services Medicare allows in a specific period for the corresponding diagnosis.

When custodial care is given:

  • Consists of any non-medical care that can reasonably and safely be provided by non-licensed caregivers.
  • Can take place at home or in a nursing home.
  • Involves help with daily activities like bathing and dressing. In some cases where care is received at home, care can also include help with household duties such as cooking and laundry.
  • May be covered by Medicaid if care is provided in a nursing home setting and not at home.

Before caring for a beneficiary who is not terminally ill (hospice providers).

Before caring for a beneficiary who is not confined to the home or does not need intermittent skilled nursing care (home health providers).

Before furnishing a preventive service usually covered but Medicare will not cover in this instance because of frequency limitations.

Before furnishing an item or service Medicare will not pay because (durable medical equipment, prosthetics, orthotics, and supplies [DMEPOS] suppliers):

    • The provider violated the prohibition against unsolicited telephone contacts
    • The supplier has not met supplier number requirements
    • The supplier is a non-contract supplier furnishing an item listed in a competitive bidding area
    • The beneficiary wants the item or service before Medicare gets the advance coverage determination.


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