by Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
October 16th, 2014
Q: What is the ABN form used for?
A: The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due to services not being deemed medically reasonable and necessary per Medicare guideline.
Q: When are ABNs mandatory for use?
A: According to Medicare rules, the ABN is the required method for communicating to Medicare patients their personal responsibility for payment of services received. To be clear, the ABN is mandatory for use only for services generally covered and governed by Medicare that may likely be or will be deemed "not reasonable and necessary". For chiropractic, this is only the 98940-98942 service codes. This allows the patient the opportunity to make an informed decision regarding receiving and paying for these services.
Q: Can ABNs be used to communicate Medicare non-coverage / non-payment of other non-covered services?
A: Yes they can. To a practice, this would be considered "voluntary ABN use". ABNs are used by practices that elect to do so, though it is not mandatory, to identify services or items that are not covered by Medicare or statutorily excluded from Medicare benefits.
In years past, Medicare did have a separate form that was required for use to report these non-covered and excluded services. That form however, has long since been retired. With the retirement of this form came the "voluntary ABN use" description as noted in the paragraph above. Practices that elect to not use the ABN for this purpose described above, often put verbiage relating to Medicare coverage and benefits onto the practice Financial Policy so as to inform Medicare patients and obtain acknowledgment of patient responsibility for non-covered items and services. ChiroCode also has a form that can be downloaded, which is entitled 'Notice of Medicare Coverage for Chiropractic Care'. This form too, allows a practice to clearly identify the chiropractic coverage and benefits of Medicare as well as the financial responsibilities of the patient for those non-covered and otherwise excluded items or services that may be rendered in chiropractic practices.
The method that individual practices elect to use in order to communicate the limitations of Medicare coverage and patient responsibility for these items or services should be clear. Patients should not be left to assume or guess what may or may not be covered by Medicare. Preserving patient relationships and avoiding misunderstandings, miscommunications, and patient complaints is an essential component in protecting a practice from other liabilities.
Q: When do I use an ABN form?
A: As a patient transitions into the maintenance phase of care (also considered Not Reasonable & Necessary or Not Medically Necessary), an ABN must be provided to the patient. A description of the service(s) rendered, the reason Medicare may not or will not pay, as well as the estimated cost is required to be properly disclosed.
Per Medicare, a patient would be transitioned to preventative or maintenance care when further clinical improvement cannot reasonably expected from continuous ongoing treatment.
Q: Can I offer the ABN to everyone just in case?
A: Medicare Learning Network ABN Booklet ICN 006266 states on page five that we are prohibited from issuing ABNs on a routine basis (that is, where there is no reasonable basis to expect that Medicare may not cover the item or service). Simply stating that Medicare could deny anything anytime is not a "reasonable basis". A "reasonable basis"' would be that you know Medicare's guidelines and the questionable service does not meet them.
Using a "blanket" ABN is not permitted. An example of a "blanket" ABN would be identifying multiple services on an ABN "just in case" they are rendered to a Medicare patient. Having all Medicare patients sign an ABN, again, "just in case", would also be considered a "blanket" ABN.
By using the –AT modifier on the CMT codes, you are telling Medicare that you believe that the service is payable (i.e. medically necessary). Chiropractors should get familiar with what Medicare considers to be medically necessary, and bill according to their guidelines. They should then use the -AT, expect to get paid, and appeal if denied. If they don't meet the criteria according to the Medicare Benefit Policy Manual, chapter 15, section 240, and their Local Coverage Determination, they should consider it maintenance, and issue an ABN. Please see Chapter 2 in the 2018 ChiroCode DeskBook for specifics on what ChiroCode teaches about the ABN.
Q: Do I have to use the ABN form?
A: Practices are required to adhere strictly to Medicare guideline and rules if treating Medicare patients as either a par or non-par provider. Of course, to treat Medicare patients with chiropractic services you must be enrolled with Medicare. So, yes, the ABN must be used when applicable and the guidelines for proper use of the ABN must be followed.
Q: How often does an ABN need to be updated?
A: According to the Medicare Claims Processing Manual (Chapter 30) and MLN booklet icn006266 "providers may issue a single ABN to a patient receiving the same service multiple times on a continuing basis. ABNs for a repetitive service can be effective for up to one year." The ABN for ongoing services must describe the services rendered. If the delivery of the repetitive service exceeds one year or if the service provider changes, a new ABN must be issued. If a different service is provided than that identified on the already signed ABN, a new ABN must be issued for that new service.
Also, if an ABN had been previously issued for a patient that now requires active care, a new ABN should be issued again once that patient is released to maintenance care.
Q: Where can I learn more about using ABNs?
A: The ABN form and instructions can be obtained directly from Medicare by visiting medicare.gov and searching for ABN. This includes both Spanish and English versions of the ABN as well as Medicare's own instruction manual. You can also search your local Medicare carrier website for publications relating to the ABN. See also Chapter 2.2 in the current ChiroCode DeskBook.
It is important to note that the ABN form being used must be the most current available. The ABN was updated recently and the new form (CMS-R-131) to use became effective on June 21, 2017. This version number is listed on the lower left corner of your ABN form which should be dated (Exp. 03/2020). Any earlier version being used is not considered valid by Medicare.