W hen is the right time to get an Advance Beneficiary Notice (ABN) signed by a Medicare patient? The use of official Medicare ABN forms is one of the most misunderstood processes in our profession. Don't shrug off improper ABN use as "no big deal" as it's a requirement that is regulated by Medicare and can cause more trouble than you may think! ABN use has both reimbursement and compliance elements surrounding its proper use and you don't want to get stuck in a nasty ABN mess! ABNs are meant to be used to "pre-notify" a patient that a service or item may be denied for medical necessity or any other reason. Because only Medicare can make the determination to cover or deny a service, an ABN is required and mandatory for the financial liability protection of the physician. When Medicare makes the determination that the service is not payable by Medicare, the signed ABN ensures the doctor's ability to collect the fee from the patient. The ABN form gives notice to the patient that the service may be, or is likely to be, denied and thatthey will be financially responsible for payment if they elect to continue with the service. This is why it must be done BEFORE the treatment is rendered. If ABN notification is not given to the patient, under Medicare's rules and regulations, the physician may not collect the fee if it is, indeed, denied by Medicare. One of the most critical things to understand (and one of the most misunderstood and poorly explained rules) is that the official Medicare ABN form is ONLY required when "an otherwise COVERED service is expected to be denied" . Let's first be clear about which services are defined by Medicare as "covered services". This is easy enough for chiropractors, because there are only three COVERED codes - 98940, 98941, and 98942. These are the SPINAL Chiropractic Manipulative Treatment (CMT) codes, and are the ONLY codes Medicare will currently consider for payment. So to understand this correctly - an ABN is only required when 98940, 98941, and 98942 are expected to be denied for reimbursement for any reason, on a given visit. Because chiropractors provide and bill for many other services in the office, such as exams, x-rays, and therapies, many think they are required to use the official ABN form for disclosing this non-coverage to Medicare patients. However, these "statutorily non-covered" are NOT required to be explained on an official ABN form. Medicare expects you to notify the patient, but it's not required on this official form. It's certainly considered best practice to properly explain your fees, what's covered, and what your patient should expect to pay out of pocket. IF you CHOOSE to notify patients of statutorily non-covered services on an official ABN form, you are participating in what CMS calls "voluntary ABN use" and this has a whole separate set of rules. Voluntary ABN usage is when you make a choice to use Medicare's official ABN form to notify patients of the costs and non-coverage of codes Medicare defines as statutorily non-covered services as we noted above. If you elect to use the official ABN form for notification concerning these services, the patient should not be asked to make a choice of options 1, 2 or 3, and should not be asked to sign the form. Keep your voluntary ABN forms separate from your required ABN forms (that do require a signature and a choice of box 1, 2 or 3). Do not mix your CMT codes with these non-covered codes on the same form. For that reason, we recommend you consider a different form of notice, for the exams, xrays, and therapies, such as on your office letterhead or some other form, like Patient Media's Medicare Worksheet, used at the end of visit one. Timing is also an important issue when it comes to ABN use. Why would an office provide notice to a Medicare beneficiary that they think today's adjustment may not be covered? Most patients come into your office the first time with a complaint that is going to require Medicare's definition of "Active Treatment". There are very specific definitions for this care, of acute and chronic treatment, and more importantly, of what Maintenance care is. There is a very spe- cifictimewhen Medicare would likely stop paying for this active treatment, according to these definitions, when the care crosses over to maintenance. THAT is the time when you must give notice that Medicare is likely to discontinue payment, and the patient can decide if they want to continue. Our experience is that FEW doctors know how to identify this critical juncture, and miss the time when the ABN should be signed. Audits and reviews by Medicare at a later time usually uncover these errors and doctors must pay back Medicare for the visits beyond when the ABN should have been signed, and that's when more devastating audits tend to occur. For correct ABN usage, follow these steps: Prior to treatment on the visit where the pa tient's condition is likely NOT to continue meet ing Medicare's definition of medical necessity, speak to the patient about it. Fill the form out EXACTLY as required, and ask the patient to select option 1, 2 or 3, regarding today's adjustment. 3. If the patient Selects Option 1, provide the service, collect your fee, and submit the bill, using not an AT modifier, but a GA modifier, indicating that it was not active treatment, and the ABN was signed. 4. If the patient selects Option 2, provide the service, collect your fee, and you don't have to bill to Medicare at all. If the patient selects Option 3, they are stating that they do not want the service. For any of these options, give a copy of the ABN to the patient, file the original, and move on. Explain to the patient that if they have a significant flare up or new condition, Medicare can be billed again and this ABN would be null and void. As long as maintenance care continues without interruption, the active ABN is good for one year. If a patient refuses to sign an ABN form, that should be annotated on the form and kept in the patient's record. ABNs must be retained for at least five years in the medical record from the time services ended unless your state requirements are longer. ABN use is required. Its rules for use are clearly defined by Medicare and neglecting to use them properly can cause both compliance and reimbursement concerns. Take the time to develop an easy system for properly executing ABN forms in your office and enjoy peace of mind! Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and, since 1983, Itas been providing chiropractors i vith reimbursement and compliance training, advice and tools to improve the financial performance of t/ieir practices. Kathy is known as one of our professions foremost experts on A ledicare andean be reached at (855) TEAMKMC or info(qikmcnfvversity.com
