An Advance Beneficiary Notice (ABN) is a written notice given to a Medicare beneficiary before providing an item or service that you expect Medicare will deny. In the chiropractic setting, it is used for the following reasons:
- Medicare never pays for chiropractic maintenance care.
- Medicare does not pay for chiropractic manipulative treatment more than X number of visits for your diagnosis.
- Your condition does not support the need for this level of service.
- Your condition does not support the need for more than one visit per day.
The purpose of an ABN is to inform the beneficiary that Medicare will not likely pay for a certain item or service in a specific situation on the basis of medical reasoning and necessity, even if Medicare might pay for the item or service under different circumstances.
General Information Regarding ABN Forms
Routine Notices Prohibition: Generic and blanket notices. Physicians should not give ABNs unless the physician has some genuine doubt about whether Medicare will make payment.
Generic ABNs: Routine ABNs that do no more than state Medicare denial of payment is possible or that the physician never knows whether Medicare will deny payment. These types of ABNs are not considered acceptable.
Blanket ABNs: A physician should not give an ABN unless the physician has some genuine doubt regarding the likelihood of Medicare payment. Giving ABNs for all claims, items or services is not acceptable practice.
Signed Blank ABNs: A physician is prohibited from obtaining beneficiary signatures on blank ABNs and then completing them at a later time.
Routine ABN Prohibition Exceptions: ABNs may be routinely given only in the following exceptional circumstances: 1) services which are always denied for medical necessity; and 2) certain frequency-limited services - when any service is to be furnished for which a frequency limitation on coverage has been established.
Delivery of ABN: The delivery of an ABN occurs when the beneficiary has both received the notice and can comprehend its contents, plus the following:
The physician (or staff) should hand-deliver the ABN to the beneficiary. The ABN must be prepared with an original and at least one copy. The physician must retain the original and give the copy to the beneficiary.
- Delivery of a notice was not properly done unless the beneficiary was able to comprehend the notice.
- A beneficiary has not received proper notice in any case where the physician refused to answer inquiries from the beneficiary.
- A patient must be notified far enough in advance of receiving a medical service that the patient can make a rational, informed, consumer decision without undue pressure. As a general rule, ABN delivery should take place before a procedure is initiated and before physical preparation of the patient (e.g., disrobing) begins.
Approved Notice Language: Physicians must use approved ABN forms. Physicians are permitted to customize the header, "Items or Services" and "Because" areas. The ABN must be only one page in length and may be modified only in the specified user-customizable sections. The standard sections of the forms may not be modified in any respect; they must be identical to the replicable PDF.
Proper Use of the ABN: When an ABN should be given and whether an ABN should be given in a particular instance depends on the physician's expectation of Medicare payment or denial:
- If the physician expects Medicare to pay, an ABN should not be given.
- If the physician "never knows whether Medicare will pay," an ABN should not be given.
- If the physician expects Medicare to deny payment, the next question is: "On what basis is denial expected?"
- If the service is not a Medicare benefit, the ABN should not be given.
- If Medicare is expected to deny payment for the service because it is not reasonable and necessary under Medicare program standards, the ABN should be given.
Instructions for Filling in the ABN Form
- 1a. The header of the ABN form should have the physician's name, address and telephone number.
- 1b. "Patient name" line: The physician enters the name of the patient.
- 1c. "Medicare Health Insurance Claim Number (HICN)" line: The physician enters the patient's Medicare HICN.
- 1d. Customizable boxes: In the "Items or Services" box, the physician specifies the health care services for which they expect Medicare will not pay. HCPCS codes are not acceptable as descriptions in and of themselves. In the box "Because," the physician gives the reason(s) they expect Medicare to deny payment.
- 1e. "Estimated Cost" line: The physician may provide the patient with an estimated cost of the services. The lack of an amount on this line, or an amount that is different from the final actual cost, does not invalidate the ABN.
- 1f. Options 1 & 2 boxes: The patient must personally select an option. Pre-selecting options is prohibited.
- 1g. "Date" line: The patient should enter the date on which they signed the ABN. On the "Signature of patient" line, the patient or authorized representative must sign their name.
After the patient has signed the ABN form, you are required to continue to submit your claims (even though you will be denied) with the GA modifier. Example: 9894X GA. For more detailed information on the proper use of the ABN form, go to http://new.cms.hhs.gov/manuals/downloads/clm104c30.pdf.
Dr. Marty Kotlar owned and operated a successful chiropractic practice for 12 years and a multi-specialty practice for four years. The president of Target Coding, Dr. Kotlar is certified in CPT coding and health care compliance, has authored eight books chiropractic coding, compliance and documentation, and conducts periodic webinars for Discount Chiropractic Supplies on compliance and coding.