Using the Medicare ABN form


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Practice Management Coding Questions

Using the Medicare ABN form
By Marty Kotlar, DC, CHCC, CBCS

Tell me about the Medicare Advance Beneficiary Notice (ABN) form. Should I use it on the initial visit? Does the patient need to sign one every visit? Once the patient signs it, how do I bill Medicare?

The Medicare Advance Beneficiary Notice (ABN) form 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 because:

• Medicare does not pay for chiropractic maintenance care;

• Medicare does not pay for chiropractic manipulative treatment more than a specific number of visits for the diagnosis;

• The patient's condition does not support the need for this level of service; or

• The patient's 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 probably not pay for a certain item or service in a specific situation on the basis of medical reasonableness and necessity, even if Medicare might pay for the item or service under different circumstances.

This allows the beneficiary to make an informed consumer decision about whether or not to receive the item or service for which he/she may have to pay out of pocket or through other insurance.

It's important for you to follow these ABN guidelines:

1. Routine notices prohibition. Do not give an ABN unless you have some genuine doubt that Medicare will make payment.

2. Generic ABNs. Generic ABNs are routine ABNs that do no more than state that Medicare's denial of payment is possible or that the physician never knows whether Medicare will deny payment. Such ABNs are not considered acceptable.

3. Blanket ABNs. Do not give an ABN unless you have some genuine doubt regarding the likelihood of Medicare payment. Giving ABNs for all claims, items, or services is not an acceptable practice.

Medicare Advance Beneficiary
Notice form completion

The ABN form must be completed properly. Here are line-by-line instructions:

• The ABN's header. This contains your name, address, and telephone number.

• Patient name. Enter the name of the patient.

• Medicare Health Insurance Claim Number (HICN). Enter the patient's Medicare HICN.

• Customizable boxes. In the box "items or services," specify the healthcare services you expect Medicare will not pay. HCPCS codes by themselves are not acceptable as descriptions. In the box "because," give the reason(s) why you expect Medicare to deny payment.

• Estimated cost. 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.

• Options 1 and 2. The patient must personally select an option — to accept the service or decline services. Preselecting an option for the patient is prohibited.

• Date. The patient enters the date on which he/she signed the ABN. In the "signature of patient" blank, the patient or authorized representative signs his or her name.

4. Signed blank ABNs. Medicare prohibits obtaining a beneficiary's signature on a blank ABN and then completing the form later.

5. Routine ABN prohibition exceptions. You may routinely give an ABN only in the following exceptional circumstances:

• Services that are always denied for medical necessity; and

• Certain frequency-limited services (services for which a frequency limitation on coverage has been established).

6. Delivery of ABN. The delivery of an ABN occurs when the beneficiary has both received the notice and can comprehend its contents, plus:

• The physician (or his/her staff) hand-delivers the ABN to the beneficiary. The ABN must be prepared with an original and at least one copy; you retain the original and give the copy to the beneficiary;

• The beneficiary is able to comprehend the notice; and

• A patient is notified far enough in advance of receiving a medical service to 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 (such as disrobing) begins.

7. Approved notice language. You must only use approved ABN forms. You are permitted to customize the header, the "items or services," and the "because" areas. The ABN can be only one page 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.

8. Proper use of the ABN. When and whether to give an ABN in a particular instance depends on your expectation of Medicare payment or denial:

• If you expect Medicare to pay, do not give an ABN;

• If "you never know if Medicare will pay," do not give an ABN;

• If the service is not a Medicare benefit, do not give an ABN; and

• If Medicare is expected to deny payment for the service because it is not reasonable and necessary under Medicare program standards, do give an ABN.

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.

Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, offers continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, through his Web site at www.TargetCoding.com, or by e-mail at drkotlar@targetcoding.com.

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