The ABC's of ABN's

John Spiezio
Feb 1
3 min read

Master the use of ABN's - It's as simple as A-B-C!

Medicare rules can be confusing—but ABNs don’t have to be.

This quick, practical guide breaks down when an ABN is required, when it’s not, and how to issue one correctly so you stay compliant, protect reimbursement, and avoid costly mistakes.

If you’ve ever wondered “Do I really need an ABN here?”—this is the clarity you’ve been looking for.

🧾 What is an ABN

An Advance Beneficiary Notice (ABN) (CMS-R-131) is a written notice given to a Medicare patient before care is provided when a provider reasonably expects Medicare will not pay for part or all of the item or service. It protects the provider’s ability to bill the beneficiary if Medicare denies payment and informs the beneficiary of that potential financial responsibility.

✅ When an ABN Must Be Issued

An ABN is required before providing services that Medicare usually covers but is expected not to cover in the specific situation because it may not be considered medically reasonable and necessary or meets another denial criterion. Examples include:

Services that are not medically reasonable and necessary for the beneficiary’s condition.
Services where frequency limits have been exceeded.
Situations where the beneficiary lacks required prior authorization, and denial is likely.

🗓️ When an ABN Is Not Required

An ABN is not required for:

Services that are never covered by Medicare (statutory exclusions), although a voluntary notice is recommended as a courtesy.
Services provided under Medicare Advantage plans (separate rules apply).
Emergency or urgent care situations where issuing an ABN could be coercive.

📝 How and When to Issue an ABN

Timing & Delivery

The ABN must be given before the service or item is provided, and far enough in advance that the beneficiary (or authorized representative) can make an informed choice.
It must clearly explain why Medicare might not pay.

Content & Completion

Use the current CMS-approved form (CMS-R-131). Forms with old expiration dates are not valid; since June 30, 2023, only the renewed form is valid.
All required fields must be filled in, including a specific description of the item/service, reason for expected denial, and estimated cost where appropriate.

Signature & Copies

The beneficiary or their representative must sign and date the ABN.
Give the beneficiary a copy and retain the original per Medicare records requirements (typically 5 years).

Refusal to Sign

If the patient refuses to sign, document the refusal on the form. You may still provide services, but the provider may be at financial risk.

📌 Important Compliance Rules

No Routine or Generic ABNs

Providers must not issue ABNs routinely for all services or without a reasonable basis for expecting denial. Blanket ABNs are not compliant.

Proper Basis Required

There must be a specific reason Medicare probably will not pay—general statements like “Medicare might or might not pay” are not valid.

Medicare Billing Consequences

If a required ABN is not issued or is invalid, the provider cannot bill the patient if Medicare denies the claim and may be liable for the charges.

👉 ABCs of ABNs: Key Takeaways for Providers

🧭Outpatient Physical Therapy ABN Decision Flow Chart

In summary, understanding the ABCs of ABNs empowers outpatient physical therapists to navigate Medicare Part B requirements with confidence. By knowing when an Advance Beneficiary Notice is required, recognizing common red flags for denial, and documenting services accurately, clinicians can protect both their practice and their patients. Clear patient communication, proper use of the CMS-R-131 form, and adherence to Medicare guidelines ensure compliance, reduce claim denials, minimize unexpected costs, and maintain transparency in support of informed decisions for care turning a complex regulatory process into a straightforward, manageable approach of every outpatient physical therapy practice.