![]() ![]() If such services are non-covered after full adjudication, the beneficiary remains liable for the services. All services on such claims with occurrence code 32 must be covered charges, even if the result of full adjudication of these claims is expected to be that services will be found to be non-covered. This code must be employed if this specific ABN form is given, and condition code 20 will not be used on the subsequent claim (i.e., no charges will be submitted as non-covered). Occurrence code 32 on a claim signifies that an ABN, Form CMS-R-131, was given to a beneficiary on a specific date. Medicare reviews all home health (HH)Īnd skilled nursing facility (SNF) services in question on these bills using condition code 20 to make a payment determination. ![]() Providers may directly collect payment from beneficiaries in such cases for non-covered charges, but if, upon review, Medicare decides a service in question is actually covered and pays, providers must return any payment collected from beneficiaries for these services. Note that condition code 20 may be used when: (1) a Home Health (HH) ABN, Form CMS-R-296, is used because payment will be made under the HH Prospective Payment System (PPS) or (2) a hospital or SNF inpatient notice of non-coverage is provided, since a Form CMS-R-131 will not be given in these cases.Ĭlaims are billed with condition code 20 at a beneficiary’s request, where the provider has already advised the beneficiary that Medicare is not likely to cover the service(s) in question. An ABN, specifically Form CMS-R-131, should not be employed when condition code 20 is used. If an ABN is given, condition code 21 cannot be used.Ĭlaims with condition code 20 may be submitted with both covered and non-covered charges. An advance beneficiary notice (ABN) is not required in these cases. If an FI receives a completely non-covered claim with either a condition code 20 or a condition code 21, process the claim through all systems.īeneficiaries are assumed to be liable on claims using condition code 21, since these claims, sometimes called “no-pay bills” and having all non-covered charges, are submitted to Medicare to obtain a denial that can be passed to subsequent payers. Condition Codes 20 and 21, Occurrence Code 32 ![]()
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