Medicare: ABNs


The latest version of the Advance Beneficiary Notice of Noncoverage (ABN)—release date of 3/2011 printed in lower left hand corner—is now available for immediate use and can be accessed below. Mandatory use of this version begins on Januray 1, 2012. All ABNs with the release date of 3/2008, that are issued on or after January 1, 2012, will be considered invalid. The form is considered by CMS to be an Office of Management and Budget (OMB) form and therefore must be replaced every three years.
 

When to Use the ABN

It's Normally A Covered Service, But It Isn't Payable Because It’s Not Medically Necessary

If you have reason to believe that the treatment of a Medicare beneficiary for a particular treatment date is maintenance care, therefore being considered not reasonable and necessary and not payable by Medicare, you would have the beneficiary sign an Advance Beneficiary Notice (ABN) prior to providing care.  The ABN is the form that is used when a normally covered service (such as spinal manipulation) will be denied due to lack of medical necessity. Using the ABN in this manner is mandatory if payment is collected for the service. 

The ABN May Also Be Used For Non-Covered Services

The ABN may also be used for non-covered services (anything that is NOT spinal CMT—CPT codes 98940, 98941, 98942).  This includes exams, modalities, x-rays, labs, etc.  Using the ABN in this manner is purely voluntary.

Template ABN and Instructions for Completion:
• Customizable/Fillable ABN
• Sample Completed ABN  form for maintenance care  
• Instructions on filling out the ABN

More Details

First Things First:
• Under Medicare, the only covered service for doctors of chiropractic is manual manipulation of the spine to correct a subluxation (CPT codes 98940, 98941, 98942).
• Only active care (acute and chronic) is payable. Maintenance care is not payable, although it is still spinal manipulation and therefore normally a covered service.
• Knowing that you can have a covered service which isn't payable is a very important point to understand for beneficiary notification purposes.

A few points:
 

• When notifying the beneficiary, you must use the ABN developed by CMS (CMS-R-131, version 03/2011).
• "Blanket" ABNs are not permissible.
• The ABN is date-of-service specific, meaning that you can't just have one signed every once in a while and be on target—you have to have a reasonable expectation that that particular visit is not payable.  Once an ABN has been signed for the purpose of indicating maintenance therapy, that ABN is valid for that series of maintenance treatment, until there is an exacerbation or any provision of active care, for up to one year.  Once there is an exacerbation or new active treatment, any maintenance care following would require a newly delivered ABN.
• The proper delivery of an ABN is very formalized and detail-specific.
     o Instructions on how to complete the ABN
• The release of the most recent ABN form does not automatically mean doctors of chiropractic no longer have to file maintenance care claims.  If the beneficiary chooses to select the "Option 2" box, indicating they wish Medicare not be billed, then you can NOT bill Medicare. Please note this is a decision to be made by the beneficiary; you should not influence their choice.  The new form, in and of itself, does NOT mean doctors of chiropractic "no longer have to bill for maintenance care." Aside from the exception above, maintenance care MUST STILL BE FILED.
• Doctors must verbally review the form with patients prior to their signing.
• A Spanish-language version is available.
 

Resources

• Instructions for completing the ABN
 New CMS ABN Form (mandatory January 1, 2012)
• New CMS ABN Form in Spanish (mandatory January 1, 2012)
• CMS Announcement of new ABN form
• CMS' Beneficiary Notices Initiative Webpage
• Full text of Medicare Claims Processing Manual Chapter 30, Financial Liability Protections