Advance Beneficiary Notice of Noncoverage/National Correct Coding Initiative

ABN

Services denied as not reasonable and medically necessary, under Section 1862(a) (1) of the Social Security Act, are subject to the Limitation of Liability (ABN) provision. The ABN is a notice given to beneficiaries to convey that Medicare is not likely to provide coverage in a specific case. Providers must complete the ABN and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice.

The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the provider must retain the original notice on file.

Complete instructions and the ABN form (CMS-R-131) can be found on the CMS Beneficiary Notices Initiative (BNI)

NCCI

The purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains
one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include PTP code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual. The purpose of the NCCI MUE program is to prevent improper payments when services are reported with incorrect units of service.

Practitioners will utilize the PTP Coding Edit table and hospitals will utilize the hospital PTP edit table.