Medicare Part B’s advance beneficiary notice

We are all familiar with Medicare Part B’s advance beneficiary notice (ABN) of noncoverage and most Part B providers use this form on a regular basis. But did you know the concept of ABN originated from the financial liability protection provisions of the Social Security Act?

The Act, signed into law by President Franklin D. Roosevelt in 1935, established a federal safety net for elderly, unemployed and disadvantaged Americans. The Act protects beneficiaries and doctors from unexpected liability for charges associated with claims that Medicare does not pay.

The Financial Liability Provisions include:

• Limitation on liability
• Compliance
• Mandatory use of the ABN
• Voluntary use of the ABN

All these years later, it boggles the mind there is still confusion in our profession about the proper use of the Medicare Part B ABN form. Read on to find out “just the facts” and improve ABN compliance in your practice.

The mandatory ABN

The “limitation on liability” protection applies when a doctor believes an otherwise covered item or service may be denied either as not reasonable and necessary or because the item or service constitutes custodial care. And therein lies the confusion. While many believe or have been taught the mandatory ABN form is for any “non-covered” service, that simply isn’t true.

Let’s interpret the Act as it relates to chiropractic spinal adjustments. Since the ABN form is mandatory only when the otherwise covered service may not be covered that visit, it simply means that it only applies to manual manipulation of the spine when it doesn’t meet Medicare’s definition of medical necessity. For chiropractic, there are only a few times to use a mandatory ABN form:

• When the doctor believes the ongoing care may exceed the usual number of visits expected for a given diagnosis
• When the patient is receiving a second adjustment on the same date of service
• When further clinical improvement is not expected from continuous, ongoing care, and the chiropractic treatment is supportive rather than corrective in nature

Another requirement of the Act is the patient must be notified in advance, before the chiropractic spinal adjustment is provided, if he or she believes it will likely be denied [Social Security Act §1862(a)(1)]. A lack of understanding of when these services may be denied and failure to have an ABN form signed can lead to incorrect billing and financial headaches. This is where the financial protection for the doctor comes in. Without a properly executed ABN, you can’t pass the fee on to the patient when coverage of the visit is denied.

The AT modifier doesn’t mean “all the time”

Through the years, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has conducted many reviews and audits of chiropractic treatment and billing. When documentation is compared to billing, as much as 78% of the time providers were found to be billing for treatment didn’t meet the definition of medical necessity. In response to these high error rates, the AT modifier for Medicare Part B was introduced on Oct. 1, 2004. This modifier, when appended to a chiropractic manipulative treatment (CMT) code, denotes an adjustment was performed, and the provider “certifies” the service was active treatment and not maintenance care. In working with providers and their teams reviewing documentation, it’s surprising to me that some providers use the AT modifier on every single visit for Medicare Part B patients indicating that every visit should be payable by Medicare. Some providers discharge patients from active treatment and then do not provide maintenance care at all, but this is the exception to the rule in our profession. Therefore, one expects we would see treatment visits that are not AT modified when the doctor is practicing good case management. It all comes down to the documentation.

AT vs. GA modifier

Documentation for chiropractic spinal adjustments has specific requirements in Medicare Part B. The documentation in the patient’s record must meet those requirements and the definition of medical necessity as outlined. It reads:

“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition while providing a reasonable expectation of recovery or improvement of function.”

When the provider certifies that care meets this definition and is billable and payable, the CMT code is modified with an AT modifier. When the provider feels the care won’t meet that definition, the AT modifier should not be used. This is when DCs may shift financial liability for the services to beneficiaries with a signed mandatory ABN form.

The patient is directed to select from among three options when signing the ABN form.

1. Option 1 acknowledges they want the service, and they want Medicare billed so they can see the denial. This is the only option for the possibility of appeal.
2. Option 2 acknowledges they want the service, but do not want Medicare billed. If the service is not billed, there is no opportunity for appeal.
3. Option 3 acknowledges the patient does not want the service and is not going to receive the care.

When the ABN form is signed and the appropriate option is selected, the CMT code is now modified by the GA modifier. For fun, we say “Got ABN” to remember this modifier. When a bill is submitted with the GA rather than the AT modifier, the service will be denied, and financial liability assigned to the patient. Likewise, a signed ABN is the only time participating providers may collect for the CMT at the time of service.

What about a voluntary ABN?

Good communication is vital for solid patient relationships, especially when it comes to financial responsibility. Although it is not a requirement to formally notify Medicare beneficiaries in writing about excluded services that are never covered by Medicare, it just makes good business sense. Patients need to be aware of the costs associated with receiving treatment. In the typical chiropractic practice, this would include evaluation and management services, X-rays, therapy charges and personal comfort items. This is because, by definition, any service other than spinal manipulation is never covered when ordered or delivered by a DC.

Best practice is not to use the official ABN form for Medicare Part B for these statutorily excluded services. It can be confusing to patients who may not understand when adjustments are billable and that everything else isn’t a benefit. You can easily create a general notification to Medicare patients that can be placed on your practice letterhead. The advantage of doing so in this format is that it exempts you from every requirement associated with the official ABN form. For a practice concerned about the copious regulations associated with Medicare, this option keeps it a little simpler.

Medicare Advantage (Part C) plans and other commercial carriers

Advance notification to patients who think they are insured but may not be for certain services is just a good idea. If your practice participates in Medicare Advantage/Medicare Part C plans, don’t use the official Medicare ABN in these instances. Carriers that provide Medicare Advantage Plans tend to provide their own ABN forms. Be sure to check the payer portal for the appropriate form (often referred to as a beneficiary notice form or notice of Medicare non-coverage).

Likewise, advance notice outside of Medicare is also a good idea, and many times, mandatory. For services commercial payers deem experimental, unproven or investigational, the patient may not be charged without a waiver signed, similar to the Medicare ABN. Most payers have a form they’d like providers to use, but if not, creating one is acceptable. Again, these must be signed before the treatment in question is rendered.

Key takeaways

• Proper use of the ABN form is a financial protection for both the practice and the patient.
• Use the AT modifier only when the provider certifies the care meets medical necessity definitions.
• Get the ABN form signed before an otherwise covered treatment that may not be covered on that visit.
• Properly explain the options on the ABN form to patients and adhere to those wishes when billing.
• Replace the AT modifier with the GA modifier during care for which an ABN has been signed and which is not payable.
• ABNs can help prove a claim was not submitted with fraudulent intent.
• ABNs create a record of the patient’s acknowledgement the services may be found to be medically unnecessary, and it was the beneficiary’s decision to receive the service anyway.
• Don’t use the official ABN form for Medicare Part C/Advantage plans or for situations when the service provided is never covered.

Final thoughts

The mystery and frustration around the Medicare Part B ABN does not have to plague busy practices. There are simple and straightforward ways to remain compliant and protect your financial interests and those of your patients.

KATHY (KMC) WEIDNER, MCS-P, CPCO, CCPC, CCCA, better known professionally as Kathy Mills Chang, has been providing DCs with reimbursement and compliance training, advice and tools to improve the financial performance of their practices since 1983. This year, celebrating serving this profession for 41 years, Weidner leads the largest team of certified specialists under one roof in the profession at KMC University. She is one of our profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM-KMC or info@kmcuniversity.com.