ABN

For outpatient physical therapy, an Advance Beneficiary Notice of Noncoverage (ABN) is used only when you believe Original Medicare is likely to deny a service that would otherwise be covered because it is not medically necessary or exceeds Medicare coverage rules. It cannot be used to bypass Medicare coverage requirements. 

When You CAN Use an ABN

In physical therapy, common examples include:

✅ Services expected to be denied as not medically necessary

• Patient has reached a therapeutic plateau.

• Continued treatment is primarily maintenance therapy.

• No objective functional improvement is expected.

• Frequency or duration exceeds what Medicare would typically consider reasonable and necessary.

✅ Services exceeding Medicare coverage limitations

• Therapy continues after the patient has achieved goals.

• Documentation does not support continued skilled care, but the patient wants to continue treatment.

✅ Before the service is provided

• The ABN must be signed prior to treatment for the dates/services expected to be denied.

When You CANNOT Use an ABN

❌ For services Medicare never covers

• Wellness programs

• Fitness memberships

• Personal training

• Massage performed solely for relaxation

• Services that are statutorily excluded from Medicare

For these services, an ABN is optional for notification purposes but does not transfer liability in the same way because Medicare does not cover them at all.

❌ Because authorization was denied

• Medicare Part B outpatient therapy generally does not require prior authorization (except certain Medicare Advantage plans).

• An ABN cannot be used simply because an authorization request was denied by another payer.

❌ To avoid billing Medicare

• If you know the patient has Medicare and the service is Medicare-covered, you must bill Medicare.

• You cannot have the patient sign an ABN just to make them self-pay.

❌ After the service has been rendered

• ABNs are not retroactive.

• If the patient was treated and no valid ABN was obtained beforehand, the clinic may be financially liable if Medicare denies the claim.

❌ For Medicare Advantage plans

• The traditional CMS-R-131 ABN applies to Original Medicare.

• Medicare Advantage plans have their own notification requirements and denial processes. A standard ABN generally does not protect you the same way it does under Original Medicare.