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Follow these Medicare ABN rules for peace of mind

Don’t get caught by services that Medicare usually covers, but may not pay, so pay attention to the Medicare ABN form and what patients...

Don’t get caught by services that Medicare usually covers, but may not pay, so pay attention to the Medicare ABN form

Since chiropractors cannot opt out of Medicare, the Advance Beneficiary Notice (ABN) is a commonly-used form in chiropractic offices. Its importance is often underestimated, and implementation is poorly executed.

The ABN protects both the patient and doctor from unexpected liability for charges associated with claims for services that Medicare usually covers but may not pay in a particular circumstance. When used correctly, Medicare-eligible patients can make informed decisions about their financial responsibility related to otherwise-covered treatment. However, if this critical piece of Medicare compliance is not in place, the practice is left vulnerable to a variety of issues including limitation on collections, and even sanctions.

There are specific rules about when the ABN must be presented to the patient and what information must be included. ABNs can be divided into two categories: mandatory and voluntary.

The mandatory ABN form

The ABN form is mandatory when the doctor expects that an otherwise-covered service (for DCs, that’s the spinal adjustment, 98940-98942) may be denied as being not medically necessary. According to the Medicare Benefits Policy Manual, maintenance therapy is defined as “a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition.”

The doctor may determine that even though the patient’s treatment may not meet Medicare’s definition of “medically necessary,” the care is still clinically appropriate. The ABN form allows the doctor to collect payment from the patient directly and gives the patient three options:

  • The patient can choose to continue to receive care and to bill Medicare even though it is believed that the services will be denied. This option is often selected by patients who have secondary insurance that does not follow Medicare payment guidelines and will cover maintenance visits. The office will append the -GA modifier to the spinal manipulation code to indicate that the service is maintenance and that the ABN has been signed (this is the only option that allows the claim to be filed and then appealed if denied);
  • The patient can choose to continue to receive care but to stop billing Medicare;
  • The patient can choose to stop receiving treatment.

Patients should not be forced into choosing a particular option or be given a form where a selection has already been made for them. Once completed and signed, the ABN is valid for up to one year or until the patient’s condition changes due to an exacerbation of the current complaint, or there is a new illness/injury which is called a “triggering event.”

The voluntary ABN form

Statutorily-excluded services, those services that Medicare never covers when ordered or delivered by a chiropractor such as E/M services, X-rays or therapeutic modalities, are not subject to the mandatory ABN. There is no requirement stating that the office has to present the patient with an ABN form for these services.

It’s good business to ensure that your patients understand their financial responsibility, but using the official ABN form from Medicare can expose you to unnecessary rules. The regulations dictate that if you elect to use the official ABN for voluntary notice, the patient can’t be asked to sign it and they can’t choose an option. For this reason, we encourage practices to utilize a different form of notice. Even writing an explanation on your office letterhead and presenting it along with your financial policy will suffice. This notice will include all the services that Medicare never covers and should be distinct from your mandatory ABN.

Not a work-around

We are aware of some providers who decide to execute their version of “opt-out” by telling patients they are not enrolled in Medicare and that if they want to be seen in the office, they must sign this ABN and pay cash. The office will not bill the Medicare administrative contractor on their behalf. This is a violation of the Mandatory Claims Submission Act of 1990 and a violation of the opt-out rule that affects chiropractors.

If you are not enrolled, that means you can’t touch Medicare patients, even for an excluded service, unless the patients have exercised their right to control their Protected Health Information in your office. If you are not enrolled in Medicare, don’t use an ABN form. It’s a mistake you don’t want to make.

Commonly-seen ABN issues

Poorly-written ABNs are often the result of a lack of training and understanding of Medicare requirements. It’s never a good idea to borrow a sample ABN form from your buddy down the street or from a random internet search since many lack key elements that customize it for your office.

Here are some things to look for in your ABN form:

  • Ensure that your office is using the latest version of the ABN form. The current version (CMS-R-131) has an expiration date of March 2020. The ABN is not always updated every year. There are versions available for both participating and non-participating Medicare providers.
  • Notifier information at the top of the ABN must be completed with the name, address and telephone number of the provider
  • Each blank associated with the letter “D” should be filled in. The patient has to know what they are signing. Don’t have the patient sign a blank form. Make a template.
  • ABNs must include cost estimates. Price ranges are acceptable for codes 98940-98942, or you can include the Medicare limiting or allowed charge instead of your actual fees.
  • New ABN forms should not be signed at every visit, whether active or maintenance. They are valid for up to one year unless the patient has an exacerbation or a new condition. While signing one for every visit of maintenance isn’t a violation, it’s not required.
  • Do not mix maintenance spinal manipulations and statutorily-excluded services on the same ABN form.
  • Only Medicare patients should sign the ABN form. Patients with Medicare Advantage Plans or any other third-party payers should not. Check with the payers you use most often to see if they have their own disclosure for non-covered services that will afford you the same type of protection as the ABN.
  • Provide an explanation of why you believe the service will be denied, such as “Medicare does not pay for maintenance care” or “Medicare does not pay for more than one spinal manipulation per day.”
  • The patient needs to receive and sign the ABN form before any non-covered services are rendered. You are not allowed to backdate the ABN form.

‘Always being a nuisance’

The only permitted alterations to the ABN form are the ones mentioned above. Once your office has the proper form in place, it is important to train your staff on its use.

Encourage patients to ask questions and review all of their options so that they can make an informed decision. Because the language of the ABN may be confusing to some beneficiaries, it is important to make sure they are clear on its intended purpose and meaning.

Although the Advance Beneficiary Notice may seem like it’s “Always Being a Nuisance,” it can help to financially protect your office from unpaid claims and ensure that you are staying compliant with Medicare’s regulations.

KAREN SEDORE, DC, CPCO, is a coach/specialist with KMC University with more than 10 years of experience working in the chiropractic profession and can be reached at

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