Definition:
• The provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient.
Example: The medical reason for performing this test does not meet medical necessity and the provider is expecting a denial. Therefore, prior to performing the service the beneficiary was given an ABN that explained that the claim would be denied.
Appropriate Usage:
• Indicates the expected denial that an item or service is not reasonable and necessary
• The most common example of these situations would be services adjudicated under a Local Coverage Decision (LCD).
• The presence or absence of this modifier does not influence Medicare’s determination for payment.
• It is appropriate to report this modifier when the beneficiary refuses to sign the ABN.
• If Medicare determines that the service is not payable, the claim denial is under a “medical necessity denial.”
Inappropriate Usage:
• When the provider/supplier has no expectation that an item or service will be denied.
• On a routine basis for all services performed by a provider/supplier.
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