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December 22, 2014

Advance Beneficiary Notice of Non-Coverage (ABN) for Chiropractic Services

The Centers for Medicare & Medicaid Services (CMS) implemented the Advance Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, to inform Original Medicare beneficiaries when Medicare may deny payment for an item or service. The current form CMS-R-131 (03/11) combines the previous versions, ABN-G (for general use) and ABN-L (for laboratory use), and the Notice of Exclusion from Medicare Benefits (NEMB) into a single notice. The dual purposes of the revised ABN are further explained below.

Medical Necessity
One purpose of the ABN is still to give notice to Original Medicare patients that Medicare is likely to deny a service based on medical necessity guidelines. This scenario applies to chiropractic manipulative treatment that no longer provides functional improvement and is considered to be maintenance therapy. ABNs allow beneficiaries to make informed decisions about whether to get the maintenance therapy and accept financial responsibility for those services if Medicare does not pay. The ABN serves as proof the beneficiary knew prior to getting the service that Medicare might not pay. If you do not issue a valid ABN to the beneficiary when Medicare requires it, you cannot bill the beneficiary for the service and you may be financially liable if Medicare doesn’t pay. Do not submit HCPCS modifier AT (active treatment) in these scenarios.

HCPCS modifier GA is used to indicate that a signed valid ABN is on file. The service will be denied, and the patient will be financially liable.

Reminder:
If the beneficiary selects optionone, he/she is agreeing to pay out of pocket for the service in question and requests that the chiropractor file a claim for that service with Medicare. With optionone selected, the beneficiary retains appeals rights if s/he disagrees with Medicare’s claim decision. The chiropractor is permitted to ask for payment from the beneficiary.

If a beneficiary selects optiontwo when he/she agrees to pay out of pocket for the service in question and does not want a claim sent to Medicare. In accordance with the ABN, the provider would not file a claim, and the beneficiary would not have appeal rights since no claim is being submitted. (Please note that the patient can change his/her mind at a future time and request the claim be submitted.)

If a beneficiary selects optionthree he/she chooses not to receive and pay for the service. No service is rendered, and no claim is filed. Since no claim is filed, the patient cannot appeal to Medicare for a payment decision.

Statutorily Excluded Services
The CMS Notice of Exclusion from Medicare Benefits (NEMB) is no longer available. Therefore, the ABN is also used in place of NEMB on a voluntary basis. While not mandated, the ABN may be provided to Medicare patients as a courtesy, to inform them of their financial responsibility for services that are statutorily excluded from Medicare benefits. Statutorily excluded services are services that, by law, Medicare cannot pay for. This includes any service provided by a chiropractor other than manual manipulation (e.g., evaluation and management (E/M) services, physical therapy, nutritional supplements and counseling).

Generally, providers are not required to submit claims to Medicare for statutorily excluded services. There are times, however, when the patient requests these services be submitted in order to obtain a denial for secondary insurance purposes. In this case, submit statutorily excluded services with HCPCS modifier GY.

The current version of the ABN is found at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.htmlExternal Website.


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