Corporate

Advance Beneficiary Notice (Occurrence Code 32)

Hospice claims for which an Advance Beneficiary Notice (ABN) was required must be billed following the process shown below. Details about when hospices are required to provide the ABN can be found at Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 30 § 50.15.3.1External PDF.

There are three situations that require issuance of the ABN to a hospice patient:

  • The beneficiary is not "terminally ill";
  • The items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary; or
  • The level of hospice care is determined to be not reasonable or medically necessary.

The ABN is only required when the beneficiary expects to receive services that the hospice believes Medicare will not cover.

When an ABN is required, the hospice must report the occurrence code 32 and the date the ABN was issued. All services on the claim must be submitted with covered charges, even if the hospice expects that Medicare will not cover the services.

Any claim submitted with an occurrence code 32 may be subject to an Additional Development Request (ADR).  If, after adjudication, the services are noncovered, the beneficiary remains liable for the services. However, if after adjudication, the services remain covered, the hospice provider will receive payment from the Medicare Program, and cannot bill the beneficiary for those covered services.

Claim Reporting When Only Some Services Related to ABN

To indicate an ABN was issued for only some services on the claim (you believe some services are covered, and some services are not covered), you must report a –GA modifier on those lines related to the ABN, in addition to reporting occurrence code 32 and the date on the claim.  Due to sequential billing requirements, hospices will need to bill all services, those the hospice expects to be covered, and those for which the ABN was issued, on one claim.

When billing a claim to Medicare with services for which an ABN was provided, the following information must be reported, in addition to all the usual claim information:

OCC CDS/DATE field FISS Page 01
(FL 31-34)
Enter the occurrence code 32 and the date the ABN was given to the beneficiary.
MODIFS field on FISS Page 02 (FL 44) Enter a GA modifier on those lines for which the ABN was issued.
Note: Required only if the claim includes both covered services, and services for which the ABN was given. If the entire claim is related to the ABN, the GA modifier is not required.
TOT CHARGE field on FISS Page 02
(FL 47)
Enter all charges as covered charges.
REMARKS field on FISS Page 04
(FL 80)
Enter remarks indicating why you feel the services should not be covered by Medicare.

CMS Educational Resources

CGS Educational Resources

Updated: 07.08.14


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