The first two articles in this series discussed the types of Medicare reviews you could be subject to and how to prove medical necessity to reviewers. The question remains, how do you protect yourself if the reviewer determines the services you rendered are not medically necessary? There are two actions you need to take; one before the fact and one after the fact.After the fact, you can (and should) appeal all denials. (Appeal procedures will be discussed in detail in part 4). Before the fact, you should have the patient sign an Advanced Beneficiary Notice of Noncoverage (ABN).
The ABN is one of the most critical Medicare forms in terms of payment for services rendered. If you use it properly, you will be able to collect your fees from the patient should the care you delivered be considered medically unnecessary. If Medicare determines that the care you delivered is medically unnecessary and you do not have an ABN on file for that patient, you will have to refund the money Medicare paid and you will not be able to collect from the patient. Here is what the ABN form instructions say:
"The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. 'Notifiers' include physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Part B (including independent laboratories), as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A. They must complete the ABN as described below and deliver the notice to affected beneficiaries or their representative before providing the items or services that are subject to the notice.
"The ABN must be verbally reviewed with the beneficiary or their representative, and any questions during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. [An ABN is never required in emergency or urgent-care situations.] Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain the original notice on file."
Some key points from the above instructions include the following:
- As a physician, you are considered a "notifier."
- Your employee or subcontractor can deliver the ABN.
- The ABN must be delivered far enough in advance that the beneficiary or representative can make an informed choice.
- The ABN must be verbally reviewed with the beneficiary or representative and all of their questions must be answered before signing.
- After signing, a copy must be given to the beneficiary or representative.
- The notifier must retain the original in their files.
According to the form instructions, you should also "[n]ote that while previously the ABN was only required for denial reasons recognized under section 1879 of the Act, the revised version of the ABN may also be used to provide voluntary notification of financial liability. Thus, this version of the ABN should eliminate any widespread need for the Notice of Exclusion from Medicare Benefits (NEMB) in voluntary notification situations."1
In other words, the ABN can also contain the notification information that was previously given to the patient on the NEMB form. This works to your advantage in the sense of protecting yourself.
The ABN can be delivered to the patient after the initial consultation, but before any services are performed. The ABN lists all services that are not paid by Medicare, such as examinations, X-rays, therapies, rehabilitation, supports, supplements, etc., under the rationale that "these services are not paid by Medicare when they are provided or ordered by a chiropractor." It also lists chiropractic manipulative therapy, reasoning that "charges are paid at the discretion of Medicare Part B and are based on their interpretation of medical necessity." Remember that the ABN must be delivered to the patient far enough in advance of delivery of care that they have time to make an informed decision.
Utilization of this procedure results in the patient being informed of what Medicare will not or may not pay with the use of a single ABN form. The patient now knows that Medicare will not pay for anything but the adjustment, and that even that is subject to Medicare's interpretation of medical necessity. This will also avoid the possible confusion that could result from the use of two separate ABNs delivered on separate occasions. You are now protected from the very first visit should Medicare decide that none of your care is medically necessary.
When you have a signed ABN in the patient's file, use the GA modifier to indicate that it is on file. When the patient is under active care, use the AT modifier to indicate active care. When you have both, you use the AT and GA modifiers in combination, with the AT modifier first. The modifier in the first position takes precedence. Remember, the GA modifier only indicates that a signed ABN is in the patient's file. It does not indicate that the patient is on maintenance care.
- Form instructions, Advanced Beneficiary Notice of Noncoverage (ABN).
Part 1 of this article appeared in the Jan. 29 issue; part 2 ran in the Feb. 26 issue. This is the third of five articles discussing Medicare claims and strategies for ensuring proper reimbursement for services performed.
Dr. Ronald Short is a certified medical compliance specialist and a certified professional coder. He has authored numerous books on Medicare including The Medicare Documentation System. He also teaches seminars on Medicare, coding, billing, documentation and compliance. You can contact him at
. More information about this and other Medicare topics is available at www.chiromedicare.net.