The Medicare Advance Beneficiary Notice (ABN) Form A Mandatory Form For Your Medicare Patients beginning October 1 By Brad M. Hayes, D.C. contact author at DCBrad1@aol.com The Medicare Advance Beneficiary Notice Form (ABN) goes into effect Tuesday, October 1, 2002. This new Medicare form is mandatory, and if you do not use it, will have very specific ramifications. The purpose of this in depth article is to give you a full understanding of the form, how it is used, when it is used, and give you the complete links to all references you will need including the actual form itself. Links to „Key¾ points in the article are listed at that point in the article and, if you received this electronically, will allow you to simply „point and click¾ if you are signed on to your web browser. Due to the length of this article, a brief summary of this paper will be presented first. The in depth discussion will follow. ADVANCE BENEFICIARY NOTIFICATION (ABN) _ An ABN is a written notice a doctor of chiropractic must give to a Medicare beneficiary before items or services that are usually paid are provided to the patient when the doctor expects these items and services to be denied by Medicare for reasons of medical necessity. Other statutory reasons according to Section 1862. See the following link for a complete list http://www.ssa.gov/OP_Home/ssact/title18/1862.htm#s10 _ The doctor must notify the beneficiary before the services are furnished that, in his/her opinion, the beneficiary will be personally and fully be responsible for payment. See section1.1 C5 of the following link. http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ The Doctor must give a copy of the ABN to the patient and retain original in the file. Section 1.1 C 1 of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ The doctor must issue an ABN each time he/she makes the assessment that Medicare payment probably or certainly will not be made. However one ABN for a series of treatments is allowed. Section 1.2 A of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ The ABN does not apply to services that are non-covered by regulation such as x-ray, E/M services and physical therapy provided by a DC. Section 1.2 H of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ Use if Chiropractic Manipulative Therapy for Maintenance or Chronic and Stable Conditions as defined by Medicare and documentation and clinical findings do not substantiate medical necessity. If the DC believes and can document that the CMT is for active treatment of subluxation and a neuromusculoskelatal condition, an ABN should not be signed. Section 1.1A 2 of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ Not to be routine or just in case. Routine signing of ABN each visit may be a RED FLAG to Medicare triggering audit or investigation. Section 1.3 A of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ DC does not waive Appeal when ABN is issued. Section 1.3 E 2c. of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ Filling out ABN form: Identifying information of the billing entity, Patient name, Medicare Health Insurance Claim Number (HICN), Services expected to be denied, Reasons for expected denial, Date and patient signature. Section 1.3 E 1 b. of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ GA Modifier must be used with billing when an ABN is given. Section 1.3 F 2. of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf _ CMS has developed a standardized ABN form (Form No. HCFA-R-131- G). This form becomes mandatory effective 10/01/02. Medicare providers are required to use this form when informing their patients when, in their opinion, Medicare will not pay for a particular item or service for reasons of medical necessity. This form is available at this link: http://cms.gov/medicare/bni/CMSR131G_June2002.pdf _ The new instructions and form are available online http://cms.gov/medlearn/refabn.asp. What Is An ABN Form? An ABN form is a form required to be given to all Medicare Beneficiaries by all Medicare Providers beginning Oct 1, 2002 when a provider expects or is certain that Medicare will deny payment for a service either based on lack of medical necessity or a few other statutory triggers. The purpose of the ABN form in the case of a chiropractor, is to inform a Medicare patient, before he or she receives adjustments that otherwise might be paid for, that Medicare probably will not pay for them on that particular occasion. The ABN also allows the patient to make an informed consumer decision whether or not to receive the care for which he or she may have to pay out of pocket or through other insurance. The ABN form allows the patient to better participate in his/her own health care treatment decisions by making informed consumer decisions. If a chiropractor expects payment to be denied by Medicare, the chiropractor must advise the patient before the care is furnished that in their opinion, the patient will be personally and fully responsible for payment. To be „personally and fully responsible for payment¾ means that the patient will be liable to make payment „out of pocket,¾ through other insurance coverage (e.g., employer group health plan coverage), or through Medicare or other federal or non-Federal payment source. For a chiropractor, this form must be given prior to an adjustment that is expected or known to be non-covered. Additionally, the chiropractor¼s billing for the CMT service must include a GA modifier if the reason for expected denial is not reasonable and necessary. See below for further explanation. To be acceptable, the ABN form must be on the approved form CMS-R-131 (G), must identify the particular services that the chiropractor believes Medicare is likely or certain to deny, and must give the chiropractor¼s reason(s) for their belief that Medicare is likely or certain to deny payment for the CMT service. Click on Link for reference of additional information http://cmshhs.custhelp.com/cgi- bin/cmshhs.cfg/php/enduser/std_adp.php?p_sid=men1- iqg&p_lva=895&p_faqid=895&p_created=1027430662&p_sp=cF9ncmlkc29ydD0mcF9yb3dfY250PTQ1J nBfc2VhcmNoX3RleHQ9QW5zd2VyaW5nIEJlbmVmaWNpYXJpZXMnIFF1ZXN0aW9ucyBBYm91dC BBZHZhbmNlIEJlbmVmaWNpYXJ5IE5vdGljZXMgKEFCTnMpJnBfY2F0X2x2bDE9NDMmcF9jYXRf bHZsMj00NSZwX3BhZ2U9MQ**&p_li= What Are The Reasons For Predicting To Know That Medicare Will Deny Payments That Should Be Given On An ABN Form? It is very important to understand that a provider has no responsibility to address services for statutorily non-allowed items or services. However, from a customer service standpoint, it may be very advisable to notify a patient. This should be done on a different form that will be identified later in this article. However, it is mandatory that if Medicare normally allows the service, but Medicare is expected to not allow for reasons of no medical necessity, or some very specific reasons to be listed within this section, then an ABN form is necessary. Simply stating „medically unnecessary¾ or the equivalent is not an acceptable reason, insofar as it does not at all explain why the chiropractor believes the service(s) will be denied as not reasonable and necessary. To be acceptable, the ABN must give the beneficiary a reasonable idea of why the physician is predicting the likelihood of Medicare denial so that the beneficiary can make an informed consumer decision whether or not to receive the adjustment and pay for it personally. The use on the ABN-G, in the customizable „Because:¾ box, of lists of reasons for denial which the particular physician has found are frequently applicable, with check-off boxes or some similar method of indicating the selection of the reason(s), is an acceptable practice. For example, „Medicare does not pay for this service for your diagnosis¾; „Medicare does not pay for this service more often than frequency limit¾; and „Medicare does not usually pay for this many services¾. Listing several reasons which apply in different situations without indicating which reason is applicable in the beneficiary¼s particular situation generally is not an acceptable practice, and such an ABN may be defective and may not protect the physician from liability. However, if more than one reason for denial could apply (e.g., exceeding a frequency limit and „same day¾ duplication), do not invalidate an ABN on the basis of citing more than one reason for denial. Reasons for medical necessity denials for a chiropractor include: _ Medicare does not usually pay for this number of services, level of service, or length of service. _ Medicare does not pay for this service based on the diagnosis rendered Section 1.1 A 1 of following link (Same as used previously) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf How Do I Know or Am Expected To Know When Medicare Will Deny Payment? The primary reasons that a chiropractor would expect or be certain that Medicare will deny payment includes such things as Medicare does not usually pay for the number of visits based on the diagnosis, or the care is considered maintenance care under Medicare program standards, or Medicare does not pay for the service based on the diagnosis when a chiropractor is treating non-musculoskeletal conditions. An additional reason may be that Medicare does not usually pay for this length of service based on Medicare program standards. Part of the new provision from the Center for Medicare and Medicaid Services (CMS) (formally HCFA) states „Physicians are expected to be knowledgeable about Medicare coverage rules on the basis of Medicare publications and professional relations activities as well as on the basis of their experience with the Medicare program and their local medical standards of practice.¾ One of the questions frequently asked by chiropractors is „does that mean I give it to every patient over 12 visits¾. The answer to that is clearly no. Medicare has a Routine Notices Prohibition. In general, the „routine¾ use of ABNs is not effective. By „routine¾ use, Medicare means giving ABNs to beneficiaries where there is no specific, identifiable reason to believe Medicare will not pay. Physicians should not give ABNs to beneficiaries unless the physician has some genuine doubt that Medicare will make payment as evidenced by the stated reason(s). Giving routine notices for all claims or services is not an acceptable practice. If Local Medicare Carriers identify a pattern of routine notices in situations where such notices clearly are not effective, they are to write to the physician and remind them of these standards. In general, routinely given ABNs are defective notices and will not protect the physician from liability. However, in certain circumstances, ABNs may be routinely given to beneficiaries because all or virtually all beneficiaries may be at risk of having their claims denied in those circumstances. Section I.1.A.2.d.ff of the Medicare Carriers Manual specify those circumstances in which ABNs may be routinely given. a. Generic ABNs: „Generic ABNs¾ are routine ABNs to beneficiaries which do no more than state that Medicare denial of payment is possible, or that the physician never knows whether Medicare will deny payment. Such „generic ABNs¾ are not considered to be acceptable evidence of advance beneficiary notice. The ABN must specify the service and a genuine reason that denial by Medicare is expected. ABN standards likewise are not satisfied by a generic document that is little more than a signed statement by the beneficiary to the effect that, should Medicare deny payment for anything, the beneficiary agrees to pay for the service. „Generic ABNs¾ are defective notices and will not protect the physician from liability. b. Blanket ABNs: A physician should not give an ABN to a beneficiary unless the physician has some genuine doubt regarding the likelihood of Medicare payment as evidenced by its stated reasons. Giving ABNs for all claims or services (i.e., „blanket ABNs¾) is not an acceptable practice. Notice must be given to a beneficiary on the basis of a genuine judgment about the likelihood of Medicare payment for that individual¼s claim. c. Signed Blank ABNs: A physician is prohibited from obtaining beneficiary signatures on blank ABNs and then completing the ABNs later. An ABN, to be effective, must be completed before delivery to the beneficiary. The Local Medicare Carrier is to hold any ABN that was blank when it was signed to be a defective notice that will not protect the physician from liability. d. Routine ABN Prohibition Exceptions: ABNs may be routinely given to beneficiaries and considered to be effective notices which will protect physicians only in the following exceptional circumstances: (Note that Option 1 of the ABN requires a claim be submitted to Medicare for the service. If you are simply giving the beneficiary advance notice of services never covered by Medicare due to statutory or other reason, use the alternate ABN form described below. An ABN fomr should only be given when the claim for the service will be filed with Medicare. ) a. Services Which Are Always Denied for Medical Necessity - In any case where a national coverage decision provides that a particular service is never covered, under any circumstances, as not reasonable and necessary under ß1862(a)(1) of the Act (e.g., at present, all acupuncture services are denied as not reasonable and necessary), an ABN that states in the „Because:¾ box that: „Medicare never pays for this item/service¾ may be routinely given to beneficiaries, and no claim need be submitted to Medicare. If the beneficiary demands that a claim be submitted to Medicare, submit the claim as a demand bill in accordance with Section 1.3.G. b. Experimental Items and Services - When any item or service which Medicare considers to be experimental (e.g., „Research Use Only¾) is to be furnished, since all such services are denied as not reasonable and necessary under ß1862(a)(1) of the Act because they are not proven safe and effective, the beneficiary may be given an ABN-G that states in the „Because:¾ box that: „Medicare does not pay for services which it considers to be experimental or for research use¾ Alternative, more specific, language with respect to Medicare coverage for clinical trials may be substituted as necessary in the ABN-G „Because:¾ box. c. Certain Frequency Limited Services - When any service is to be furnished for which Medicare has established a statutory or regulatory frequency limitation on coverage, or a frequency limitation on coverage on the basis of a national coverage decision or on the basis of the carrier local medical review policy (LMRP), because all or virtually all beneficiaries may be at risk of having their claims denied in those circumstances, the physician may routinely give ABNs to beneficiaries. In any such routine ABN-G, the physician must state the frequency limitation in the ABN-G „Because:¾ box (e.g., „Medicare does not pay for this item or service more often than frequency limit¾). CMS, along with Local Medicare Carriers have developed specific Local Medicare Policy for chiropractic in most states. References to the web site address of all Local Medicare Carriers and the Local Medical Review Policy (LMRP) for each state is given at the end of this article. It is very important that each chiropractor access the LMRP for chiropractic in their state. Most states have adopted a chiropractic policy that, based on the diagnosis, provides guidelines suggesting the need for longer or shorter care. The Mercy Guidelines were utilized as a reference for most of these guidelines along with other references. „Mercy¾ suggests that 5-18 visits over a 6-8 week period of time may be appropriate for uncomplicated conditions. The Mercy Guidelines also identify complications that may further prolong care, and may be helpful for the purpose of appeal. Medicare still requires all Medicare Carriers to „screen „ chiropractic care at 12 visits. That is based on the average number of visits that a typical Medicare patient is seen in a one-year period of time. However, most Local Medicare Carrier Advisory Committees have adopted expanded Medicare diagnoses criteria for chiropractors. Thus there is now a basis to go beyond 12 adjustments for a condition just based on the diagnosis submitted on the CMS 1500 claim form. However, here is a word of caution. The diagnosis utilized must be supported in the provider¼s documentation. A pattern of unsupported documentation of diagnoses indicating the need for prolonged care could be construed as fraudulent conduct. HCFA (now CMS) Ruling 95-1, section IVB-2., Criteria For Determining Practioner Knowledge, states that 'In accordance with 42 CFR 411.406 (Criteria for determining that a provider, practitioner knew that items or services were excluded from coverage such as custodial care or as not reasonable and necessary) and ß7300.5 of the Medicare Carriers Manual, evidence that the practitioner did, in fact, know or should have known that Medicare would not pay for a service or item includes: _ A Medicare contractor's prior written notice to the practitioner of Medicare denial of payment for similar or reasonably comparable services or items; _ Our general notices to the medical community of Medicare payment denial of services and items under all or certain circumstances. (Our notices include, but are not limited to, manual instructions, bulletins, carriers' written guides, and directives); and _ Provision of the services and items was inconsistent with acceptable standards of practice in the local medical community (refer to section V. of this Ruling). If any of the circumstances described above exists, a practitioner is held to have knowledge.' This means that if you have had your manipulation services for a diagnosis denied at visit 15 in the past, or, for example, you are outside the Mercy Guidelines, or your are treating the patent for a condition that is a non-musculoskeletal condition such as hiatus hernia, or a non-spinal area such as the rotator cuff of the shoulder, etc., there is a very real possibility that Medicare will not pay for it. In these instances, an Advance Beneficiary Notice form should be given prior to the services (CMT, manipulation) being rendered. Click on Link for reference of additional information : http://cmshhs.custhelp.com/cgi- bin/cmshhs.cfg/php/enduser/std_adp.php?p_sid=men1- iqg&p_lva=&p_faqid=893&p_created=1027430370&p_sp=cF9ncmlkc29ydD0mcF9yb3dfY250PTQ1JnBf c2VhcmNoX3RleHQ9QW5zd2VyaW5nIEJlbmVmaWNpYXJpZXMnIFF1ZXN0aW9ucyBBYm91dCBB ZHZhbmNlIEJlbmVmaWNpYXJ5IE5vdGljZXMgKEFCTnMpJnBfY2F0X2x2bDE9NDMmcF9jYXRfbH ZsMj00NSZwX3BhZ2U9MQ**&p_li= What Happens If I Do Not Give The ABN To The Patient? The primary result of not giving an ABN form to a patient will be that it exposes a physician to the risk of potential financial liability for denied items or services in cases where, in the absence of a proper ABN, the beneficiary would be held not to have known, nor to reasonably have been expected to have known, that his/her claims for the denied services he/she received were likely to be denied by Medicare. A physician held liable for such denied charges will be precluded from collecting from the beneficiary and may be required to make refunds to the beneficiary, or face possible sanctions for failure to do so. These sanctions can be very expensive. Section 1.1 5D 2 of the following link (used above): http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf The secondary result of not giving an ABN form to a patient depends on if the Local Medicare Carrier suspects that a physician is not furnishing ABNs with the intent to induce or coerce referrals for other items and/or services paid for by Medicare whereby anti- kickback statutes could be implicated, or if the carrier suspects that a physician is doing so for any fraudulent, abusive, or otherwise illegal purposes, they are to refer the case to the CMS regional office for consideration of investigation and prosecution. A complete article regarding this possibility as well as the official position of the Office of Inspector General regarding giving free services or discounts to Medicare patients is being prepared and will be distributed in the same manner this article has been distributed. Section 1.15D 7 of the following link (used above): http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf What Information Must Be Included In An ABN For A Part B Service? The physician must ensure that the readability of the ABN facilitates beneficiary understanding. No insertion into the blanks and boxes of the ABN, if typed or printed, should use italics nor any font that is difficult to read. An Arial or Arial Narrow font, or a similarly readable font, in the font size range of 10 point to 12 point, is recommended. Black or dark blue ink on a white background is strongly recommended. A visually high- contrast combination of dark ink on a pale background is required. Low-contrast combinations and block shading are prohibited. If insertions are handwritten, they must be legible. In all cases, both the originals and copies of ABNs must be legible and high- contrast. When Spanish language ABNs are used, the physician should make insertions on the form in Spanish to the best of their ability. If this is impossible, the physician needs to take other steps as necessary to ensure that the beneficiary understands the notice. The ABN¼s header should have the identifying information of the billing entity. If the billing entity is a group practice, then the group practice may have its identifying information in the header. It may be prudent for each member of a group practice to also include their name in the header, but it is not required. The physician puts his/her/its name, address, and telephone number at the top of the notice header; and may elect to include his/her/its logo (if any). Within these general rules, the physician may customize a notice header. The physician enters the name of the patient, not substituting the name of an authorized representative. The physician enters the patient¼s Medicare Health Insurance Claim Number (HICN) In the section of the ABN-G beginning „We expect that Medicare will not pay for the item(s) or service(s) ä¾, in the first box „Items or Services:¾ the chiropractor specifies the health care services for which he/she/it expects Medicare will not pay. The services at issue must be described in sufficient detail so that the patient can understand what services may not be furnished. Of course for a chiropractor, this means manipulation only. HCPCS (CPT codes 98940-98942) codes by themselves are not acceptable as descriptions. The use on the ABN of a list of the services, which the particular physician frequently furnishes, with check-off boxes or some similar method of identifying the particular services for which denial is predicted, is an acceptable practice. Listing several services without indicating which is/are applicable in the beneficiary¼s particular situation is not an acceptable practice and such an ABN is defective and will not protect the physician from liability. In the second box „Because:¾ the physician gives the reason why s/he expects Medicare to deny payment. The reason(s) must be sufficiently specific to allow the patient to understand the basis for the expectation that Medicare will deny payment. The chiropractor may customize these two boxes for their own use. „Estimated Cost¾ Line--The chiropractor may provide the patient with an estimated cost of the services. The patient may ask about the cost and jot down an amount in this space. The physician should respond to such inquiries to the best of their ability. The lack of an amount on this line, or an amount which is different from the final actual cost, does not invalidate the ABN; an ABN should not be considered to be defective by carriers on that basis. In the case of an ABN, which includes multiple items and/or services, it is permissible for the physician to give estimated amounts for the individual items and/or services rather than an aggregate estimate of costs. Amounts may be provided either with the description of services or on the „Estimated Cost¾ line. Options 1 & 2 Boxes--The patient must personally select an option. Carriers do not accept as evidence of beneficiary notice any ABN on which the physician has pre-selected an option; pre-selecting options is prohibited. In the „Date¾ blank, the patient, or his or her authorized representative, should enter the date on which he or she signed the ABN. If the date is filled in by the physician and the beneficiary or his or her authorized representative does not dispute the date, a carrier should accept that date. Carriers do not reject ABNs simply because the date is typed or printed. In the „Signature of patient ä¾ blank, the patient, or person acting on his or her behalf, must sign his or her name. Signature Requirements for ABN-G a. The beneficiary himself or herself may sign an ABN. In the case of a beneficiary who is incapable or incompetent, his or her „authorized representative,¾ as defined for ABN purposes in Section I.1.F may sign an ABN. The policy enunciation in Section I.1.F of who may be an „authorized representative¾ supersedes the previous policy that „generally applicable rules of the Medicare program with respect to who may sign for a beneficiary apply to signing notices, including ABNs.¾ The regulations on signature requirements for claims purposes at 42 CFR 424.36(b) do not apply to ABNs except that, with respect solely to ABNs for unassigned claims for physicians¼ services, someone eligible to sign for the beneficiary under 42 CFR ß424.36(b), who is an „authorized representative¾ as defined for ABN purposes in Sections I.1.F and I.1.F.3 notwithstanding, may sign an ABN. b. If the beneficiary¼s (or authorized representative¼s) signature is absent from an ABN, in case of a dispute as to the beneficiary¼s (or authorized representative¼s) receipt of the ABN, give credence to the beneficiary¼s (or representative¼s) allegations regarding the ABN, except as specified in Section I.3.F.2. c. The physician must obtain the signed and dated ABN from the beneficiary, either in person or, where this is not possible, via return mail from the beneficiary or authorized representative acting on the beneficiary¼s behalf as soon as possible after the ABN has been signed and dated. The beneficiary retains the patient¼s copy of the signed and dated ABN and returns the original. The physician retains the original ABN. These copies will be relevant in case of any future appeal. Do not require physicians and to routinely submit copies of all ABNs to you. See the following link : http://cmshhs.custhelp.com/cgi- bin/cmshhs.cfg/php/enduser/std_adp.php?p_sid=QIQ2Jvqg&p_lva=895&p_faqid=898&p_created=102743 0926&p_sp=cF9ncmlkc29ydD0mcF9yb3dfY250PTQ1JnBfc2VhcmNoX3RleHQ9QW5zd2VyaW5nIEJlb mVmaWNpYXJpZXMnIFF1ZXN0aW9ucyBBYm91dCBBZHZhbmNlIEJlbmVmaWNpYXJ5IE5vdGljZ XMgKEFCTnMpJnBfY2F0X2x2bDE9NDMmcF9jYXRfbHZsMj00NSZwX3BhZ2U9MQ**&p_li= What Are The Main Differences Between 'Limitation On Liability' (LOL) And The Refund Requirements' (RR)? As it pertains to chiropractor, LOL and RR are both financial liability provisions of the Medicare law. LOL is provided under ß1879(a)-(c) of the Social Security Act (the Act) for all assigned claims for Part B services. RR is provided for unassigned claims for physicians' services under ß1842(l) of the Act. LOL provides for program payment for denied claims in certain circumstances, and for beneficiary indemnification in certain circumstances. RR does not provide for either program payment or indemnification, but does provide that physicians, if held liable under RR provisions, must make refunds to beneficiaries of any amounts collected. See the following link : http://cmshhs.custhelp.com/cgi- bin/cmshhs.cfg/php/enduser/std_adp.php?p_sid=QIQ2Jvqg&p_lva=898&p_faqid=907&p_created=102743 1601&p_sp=cF9ncmlkc29ydD0mcF9yb3dfY250PTQ1JnBfc2VhcmNoX3RleHQ9QW5zd2VyaW5nIEJlb mVmaWNpYXJpZXMnIFF1ZXN0aW9ucyBBYm91dCBBZHZhbmNlIEJlbmVmaWNpYXJ5IE5vdGljZ XMgKEFCTnMpJnBfY2F0X2x2bDE9NDMmcF9jYXRfbHZsMj00NSZwX3BhZ2U9MQ**&p_li= The doctor Must Notify The Beneficiary Before The Services Are Furnished A patient must be notified far enough in advance of receiving a medical service so that the patient can make a rational, informed consumer decision without undue pressure. The purpose of this timely delivery rule is to avoid putting the beneficiary into a position in which she/he is already committed to receiving the item or service before receiving notice of the likelihood of denial of payment by Medicare. As a general rule, ABN delivery should take place before the Chiropractic Manipulative Service is initiated and before physical preparation of the patient (e.g., disrobing) begins. This criterion does not constitute a blanket prohibition on giving an ABN to a beneficiary after she/he has entered an examination room and is ready to receive services or items. If a beneficiary alleges she/he was coerced into accepting medical services by receiving the ABN at the last moment, the Local Carrier is to investigate the facts. If the physician clearly and obviously violated this timely delivery rule, they will hold that the notice was not properly delivered in advance of furnishing the item or service and that the beneficiary therefore is not liable. See section1.1 C5 of the following link. http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf The Doctor Must Give A Copy Of The ABN To The Patient And Retain One In The File. The physician should hand-deliver the ABN to the representative. Delivery is the physician¼s responsibility. (Carriers will consider delivery of an ABN by a physician¼s staff or employees to be delivery by the physician.) If the beneficiary alleges non- receipt of notice and the physician cannot show that the beneficiary received notice, a carrier will not consider that the beneficiary knew or could reasonably have been expected to know that Medicare would not pay; i.e., they will hold the physician liable and the beneficiary not liable. The ABN must be prepared with an original and at least one copy. The physician must retain the original and give the copy to the beneficiary or authorized representative. The copy is given to the beneficiary immediately after the beneficiary signs it. Legible duplicates (carbons, etc.), fax copies, electronically scanned copies, or photocopies will suffice. This is a fraud and abuse prevention measure. If a beneficiary is not given a copy of the ABN and if the beneficiary later alleges that the ABN presented to the carrier by the physician is different in any material respect from the ABN he/she signed, the Carrier give credence to the beneficiary¼s allegations. Section 1.1 C 1 of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf The Doctor Must Issue An ABN Each Time He/She Makes The Assessment That Medicare Payment Probably Or Certainly Will Not Be Made. However One ABN For A Series Of Treatments Is Allowed. A single ABN covering an extended course of treatment is acceptable provided that the ABN identifies all services for which the physician believes Medicare will not pay. If, as the extended course of treatment progresses, additional services are to be furnished for which the physician believes Medicare will not pay, the physician must separately notify the patient in writing (i.e., give the beneficiary another ABN) that Medicare is not likely to pay for the additional services and obtain the beneficiary's signature on the ABN. Services provided on a regularly scheduled basis under a „standing order¾ may be considered, for these beneficiary notice purposes only, as an extended course of treatment; and a single ABN is appropriate. New ABNs are required only when additional services, which are not specified by the initial course of treatment ABN and for which non-coverage is expected, are to be furnished to the beneficiary. When an ABN is to be given for a „standing order¾ the physician must specify in the „Items or Services:¾ box of the ABN-G, of the customizable box beginning „Medicare probably will not payä¾ the pertinent facts (e.g., frequency and duration) of the standing order (see Section I.3.E.1.b.v.). One year is the limit for use of a single ABN for an extended course of treatment; if the course of treatment extends beyond one year, a new ABN is required for the remainder of the course of treatment. An ABN, once signed by the beneficiary, may not be modified or revised. When a beneficiary must be notified of new information, a new ABN must be given. Section 1.2 A of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf The ABN Does Not Apply To Services That Are Non-Covered By Regulation Such As X-Ray, EM Services And Physical Therapy Provided By A Chiropractor Physicians need to use ABNs only when Medicare is expected (or certain) to deny payment on the basis of one of the following statutory exclusions: ß1862(a)(1) & (9); ß1834(a)(17)(B); ß1834(j)(1); and ß1834(a)(15) of the Act. ABNs are not required in the case of statutorily excluded items and services not listed above. Examples of exclusions for which ABNs are not required include for a chiropractor, but are not limited to: ÄPersonal comfort items; ÄRoutine physicals and most tests for screening; ÄNutritional supplements; ÄOrthopedic shoes and foot supports (orthotics); ÄServices paid for by a governmental entity that is not Medicare; ÄHealth care received outside of the USA; ÄServices by immediate relatives; ÄServices required as a result of war; ÄServices for which the patient has no legal obligation to pay; ÄOutpatient occupational and physical therapy services (See ß1862(a) of the Act for a more complete listing.) ABNs also are not required when Medicare is expected to deny payment for an item or service which may be a Medicare benefit but for which the coverage requirements (not listed above) are not met, e.g., when a service is covered only in a qualifying setting and the service in question was not provided in such a qualifying setting. Another example would be maintenance care because maintenance care is not covered by Medicare. In situations in which ABNs are not required, the lack of an ABN, by itself, will not prevent a chiropractor from collecting from a beneficiary. In situations in which ABNs are not required, physicians are neither required to nor prohibited from voluntarily giving some sort of notice to beneficiaries anyway, as a prudent customer service, however, since standard ABN forms include language asking for a claim to be submitted to Medicare, physicians who wish to give notice in these situations should not use the CMS-R-131 ABN forms. Section 1.2 H of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf Alternate CMS Approved Form For Non Covered Services CMS has approved a form that can be used on a completely voluntary basis to notify a patient of services that Medicare never covers. This form is helpful for patients in understanding the services that you perform that will not be covered by Medicare``. See the following link for an example: http://cms.gov/medlearn/nebmeng.pdf Use ABN Form If CMT For Maintenance or Chronic and Stable Conditions As Defined By Medicare And Documentation And Clinical Findings Do Not Substantiate Medical Necessity. If the DC believes and can document that the CMT is for active treatment of subluxation and a neuromusculoskelatal condition, an ABN should not be signed. This would mean that the care was for a covered condition. In general, the „routine¾ use of ABNs is not effective. By „routine¾ use, CMS means giving ABNs to beneficiaries where there is no specific, identifiable reason to believe Medicare will not pay. Physicians should not give ABNs to beneficiaries unless the physician has some genuine doubt that Medicare will make payment as evidenced by their stated reasons. Giving routine notices for all claims or services is not an acceptable practice. If a carrier identifies a pattern of routine notices in situations where such notices clearly are not effective, they are to write to the physician and remind them of these standards. In general, routinely given ABNs are defective notices and will not protect the physician from liability. However, in certain circumstances, ABNs may be routinely given to beneficiaries because all or virtually all beneficiaries may be at risk of having their claims denied in those circumstances. Section I.1.A.2.d.ff specify those circumstances in which ABNs may be routinely given. Section 1.1A 2 of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf Not To Be Routine Or Just In Case. Routine signing of an ABN each visit may be a RED FLAG to Medicare triggering an audit or investigation. Whether an ABN should be given in a particular instance depends on expectation of Medicare payment or denial. a. If the physician expects Medicare to pay, an ABN should not be given. b. If the physician „never knows whether or not Medicare will pay,¾ an ABN should not be given. c. If the physician expects Medicare to deny payment, the next question is: „On what basis is denial expected?¾ a. If the service is not a Medicare benefit (e.g., maintenance care), the ABN-G should not be given. b. If Medicare is expected to deny payment for a service which is a Medicare benefit because it does not meet a technical benefit or requirement the ABN-G should be given. c. If Medicare is expected to deny payment (entirely or in part) for the service because it is not reasonable and necessary under Medicare program standards (viz., „medical necessity denials¾ under ß1862(a)(1) of the Act), the ABN-G should be given (this is applicable to all assigned Part B items and services, and to unassigned physicians¼ services). Section 1.3 A of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf DC Does Not Waive Appeal When ABN Is Issued. The physician must obtain the signed and dated ABN from the beneficiary, either in person or, where this is not possible, via return mail from the beneficiary or authorized representative acting on the beneficiary¼s behalf as soon as possible after the ABN has been signed and dated. The beneficiary retains the patient¼s copy of the signed and dated ABN and returns the original. The physician retains the original ABN. These copies will be relevant in case of any future appeal. Section 1.3 E 2c. of the following link (same link as above) http://cms.hhs.gov/manuals/pm_trans/ab02114.pdf GA Modifier Must Be Used With Billing When An ABN Is Given. When you think a service will be denied because it does not meet the Medicare program standards for medically necessary care and you gave the beneficiary an advance beneficiary notice, the GA modifier is required to be used. The claim will be reviewed by Medicare like any other claim and may or may not be denied. The carrier will not use the presence of the GA modifier to influence its determination of Medicare coverage and payment of the service. The GA modifier should be put in the modifier block of the claim form at line 24. For additional information on this subject go to http://cms.gov/medlearn/modchtga.pdf The Standard ABN Form CMS has developed a standardized ABN form (Form No. HCFA-R-131-G). This form becomes mandatory effective 10/01/02. Medicare providers are required to use this form when informing their patients when, in their opinion, Medicare will not pay for a particular item or service for reasons of medical necessity. This form is available at this link: http://cms.gov/medicare/bni/CMSR131G_June2002.pdf For Further information, the primary reference for most questions related to the ABN form, along with the quick reference guide is found at the following link. The new instructions and form are available online http://cms.gov/medlearn/refabn.asp. An additional, in depth paper is being prepared regarding whether to file for an extension regarding the HIPAA compliance for the Electronic Health Care Transactions and Code Sets Standards code sets, which is due 10/15/02. This will be prepared by October 1. The Website address is (Http://www.cms.hhs.gov/hipaa/hipaa2) A third paper, an in depth report on the prohibition of Free and Discounted services to Medicare that was published in August by Medicare. This will be sent by October 4. The Website Address is: http://oig.hhs.gov/fraud/docs/alertsandbulletins/SABGiftsandInducements.pdf Medicare Carriers of the United States ‚ Web Site Addresses Chiropractic coverage occurs under Part B of Medicare. Following are the Part B Carriers for all states in the United States. Alabama ‚ Blue Cross Blue Shield of Alabama Web Site Address: www.cahabagba.com Local Medical Review Policy for Chiropractic: http://www.almedicare.com/provider/LMRPBFinal/Chiropractic%20Service%20(Manual %20Spinal%20Manipulations).htm Alaska ‚ Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Arizona - Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Arkansas ‚ Arkansas Blue Cross and Blue Shield Web Site Address: www.arkmedicare.com Local Medical Review Policy for Chiropractic: http://www.arkmedicare.com/provider/medpolb/ac01006.asp California ‚ National Heritage Insurance Company Web Site Address: www.medicarenhic.com Local Medical Review Policy for Chiropractic: None Listed Colorado - Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Connecticut ‚ Blue Cross and Blue Shield of Florida, Inc. (First Coast Service Options) Web Site Address: www.connecticutmedicare.com Local Medical Review Policy for Chiropractic: None listed Delaware ‚ TrailBlazer Health Enterprises, LLC Web Site Address: http://www.trailblazerhealth.com/ Local Medical Review Policy for Chiropractic: http://www.trailblazerhealth.com/lmrp.asp?ID=11&lmrptype=md Florida - Blue Cross and Blue Shield of Florida, Inc. (First Coast Service Options) Web Site Address: www.floridamedicare.com Local Medical Review Policy for Chiropractic: None Found Georgia ‚ Blue Cross Blue Shield of Alabama Web Site Address: www.cahabagba.com Local Medical Review Policy for Chiropractic: http://www.gamedicare.com/Policies/108.htm Hawaii - Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Idaho - Conneticut General Life Insurance Company Web Site Address: www.cignamedicare.com Local Medical Review Policy for Chiropractic: http://www.cignamedicare.com/partb/lmrp/id/id97001.html Illinois ‚ Wisconsin Physicians Service Web Site Address: http://www- ss.wpsic.com/medicare_web/SilverStream/Pages/Level_0_Final.html Local Medical Review Policy for Chiropractic: http://www.wpsic.com/medicare/policy/Illinois/1policies.html Indiana ‚ AdminaStar Federal, Inc. Web Site Address: www.adminastar.com Local Medical Review Policy for Chiropractic: http://www.adminastar.com/anthem/affiliates/adminastar/medb/index.html Iowa - Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Kansas - Blue Cross Blue Shield of Kansas Web Site Address: www.kansasmedicare.com/index.htm Local Medical Review Policy for Chiropractic: http://www.kansasmedicare.com/part_B/LMRP/ChiropracticService.htm Kentucky ‚ AdminaStar Federal, Inc. Web Site Address: www.adminastar.com Local Medical Review Policy for Chiropractic: http://www.adminastar.com/anthem/affiliates/adminastar/medb/index.html Louisiana - Arkansas Blue Cross and Blue Shield Web Site Address: www.lamedicare.com Local Medical Review Policy for Chiropractic: http://www.lamedicare.com/provider/medpol/ac01006.asp Maine ‚ National Heritage Insurance Company Web Site Address: www.medicarenhic.com Local Medical Review Policy for Chiropractic: http://www.medicarenhic.com/lmrp/final/ne/01-06R3.htm Maryland ‚ TrailBlazer Health Enterprises, LLC Web Site Address: http://www.trailblazerhealth.com Local Medical Review Policy for Chiropractic: http://www.trailblazerhealth.com/lmrp.asp?ID=11&lmrptype=md Massachusetts - National Heritage Insurance Company Web Site Address: www.medicarenhic.com Local Medical Review Policy for Chiropractic: http://www.medicarenhic.com/lmrp/final/ne/01-06R3.htm Michigan ‚ Wisconsin Physicians Service Web Site Address: www-ss.wpsic.com/medicare_web Local Medical Review Policy for Chiropractic: http://www.wpsic.com/medicare/policy/Illinois/1policies.html Minnesota - Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: None Mississippi ‚ Blue Cross Blue Shield of Alabama Web Site Address: www.cahabagba.com Local Medical Review Policy for Chiropractic: None Missouri (Eastern) - Arkansas Blue Cross and Blue Shield (Eastern) Web Site Address: www.momedicare.com Local Medical Review Policy for Chiropractic: http://www.momedicare.com/provider/medpol/ac01006%2Easp Missouri WesternBlue Cross and Blue Shield of Kansas, Inc. (NorthWestern) Web Site Address: www.kansasmedicare.com/index.htm Local Medical Review Policy for Chiropractic: http://www.kansasmedicare.com/part_B/LMRP/ChiropracticService.htm Montana ‚ Blue Cross Blue Shield of Montana, Inc. Web Site Address: www.medicare.bcbsmt.com Local Medical Review Policy for Chiropractic: None Nebraska ‚ Blue Cross Blue Shield of Kansas, Inc. Web Site Address: www.kansasmedicare.com/index.htm Local Medical Review Policy for Chiropractic: http://www.kansasmedicare.com/part_B/LMRP/ChiropracticService.htm Nevada ‚ Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html New Hampshire ‚ National Heritage Insurance Company Web Site Address: www.medicarenhic.com Local Medical Review Policy for Chiropractic: http://www.medicarenhic.com/lmrp/final/ne/01-06R3.htm New Jersey ‚ Empire Health Choice, Inc. Web Site Address: www.empiremedicare.com Local Medical Review Policy for Chiropractic: http://www.empiremedicare.com/Newjpolicy/njindex.htm (Look in index on left under miscellaneous for Chiropractic) New Mexico ‚ Arkansas Blue Cross Blue Shield Web Site Address: www.oknmmedicare.com Local Medical Review Policy for Chiropractic: http://www.oknmmedicare.com/provider/medpol/ac01006.asp New York ‚ Blue Cross Blue Shield of Western New York Web Site Address: www.umd.nycpic.com/ Local Medical Review Policy for Chiropractic: http://www.umd.nycpic.com/cgi- bin/bookmgr/bookmgr.cmd/BOOKS/M973-8/FRONT New York - Empire HealthChoice, Inc., Web Site Address: www.empiremedicare.com Local Medical Review Policy for Chiropractic: http://www.empiremedicare.com/Newypolicy/nyindex.htm (Look in Index on the left under Chiropractic) New York (Queens County)- Group Health, Inc. Web Site Address: www.ghimedicare.com Local Medical Review Policy for Chiropractic: http://www.ghimedicare.com/lmrp2/TableofContents.html#F North Carolina ‚ Connecticut General Life Insurance Company Web Site Address: www.cignamedicare.com Local Medical Review Policy for Chiropractic: http://www.cignamedicare.com/partb/lmrp/nc/nc97003.asp North Dakota ‚ Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Ohio ‚ Nationwide Mutual Insurance Company Web Site Address: http://www.palmettogba.com/ Local Medical Review Policy for Chiropractic: http://www.palmettogba.com/palmetto/LMRPs_PartB_OHWV.nsf/2dfb6267ec8c1dba85 256a7200679216/74832d4f3e82dd3485256c0900593fb7?OpenDocument Oklahoma ‚ Arkansas Blue Cross Blue Shield Web Site Address: www.oknmmedicare.com Local Medical Review Policy for Chiropractic: http://www.oknmmedicare.com/provider/medpol/ac01006.asp Oregon ‚ Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Pennsylvania ‚ Highmark, Inc. Web Site Address: www.hgsa.com Local Medical Review Policy for Chiropractic: http://www.hgsa.com/professionals/policy/z6h.html Peurto Rico ‚ Triple-S, Inc. Web Site Address: www.triples-med.org Local Medical Review Policy for Chiropractic: Provider Section Under Construction No LMRP on Chiropractic Identified Rhode Island ‚ Blue Cross Blue Shield of Rhode Island Web Site Address: www.rimedicare.org Local Medical Review Policy for Chiropractic: None South Carolina ‚ Blue Cross Blue Shield of South Carolina Web Site Address: www.palmettogba.com Local Medical Review Policy for Chiropractic: http://www.palmettogba.com/palmetto/LMRPs_PartB.nsf/2dfb6267ec8c1dba85256a7200 679216/a3d9435f31cde585852569690067bcbb?OpenDocument South Dakota ‚ Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Tennessee ‚ Connecticut General Life Insurance Company Web Site Address: www.cignamedicare.com Local Medical Review Policy for Chiropractic: http://www.cignamedicare.com/PARTB/lmrp/tn/tn9617.html Texas ‚ TrailBlazer Health Enterprises, LLC Web Site Address: http://www.trailblazerhealth.com Local Medical Review Policy for Chiropractic: http://www.trailblazerhealth.com/lmrp.asp?ID=11&lmrptype=md Utah ‚ Blue Cross Blue Shield of Utah Web Site Address: http://medicare.regence.com Local Medical Review Policy for Chiropractic: http://medicare.regence.com/medicare_part_b/medical_policies/policies_lmrp/ut_chiropr actic_services.html Vermont ‚ National Heritage Insurance Company Web Site Address: www.medicarenhic.com Local Medical Review Policy for Chiropractic: http://www.medicarenhic.com/lmrp/final/ne/01-06R3.htm Virginia ‚ TrailBlazer Health Enterprises, LLC Web Site Address: http://www.trailblazerhealth.com Local Medical Review Policy for Chiropractic: None Washington ‚ Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html Washington D.C. ‚ TrailBlazer Health Enterprises, LLC Web Site Address: http://www.trailblazerhealth.com/ Local Medical Review Policy for Chiropractic: http://www.trailblazerhealth.com/lmrp.asp?ID=11&lmrptype=md West Virginia ‚ Nationwide Insurance Company Web Site Address: http://www.palmettogba.com Local Medical Review Policy for Chiropractic: http://www.palmettogba.com/palmetto/LMRPs_PartB_OHWV.nsf/2dfb6267ec8c1dba85 256a7200679216/74832d4f3e82dd3485256c0900593fb7?OpenDocument Wisconsin ‚ Wisconsin Physicians Service Insurance Corporation Web Site Address: http://www- ss.wpsic.com/medicare_web/SilverStream/Pages/Level_0_Final.html Local Medical Review Policy for Chiropractic: http://www.wpsic.com/medicare/policy/Wisconsin/1policies.html Wyoming ‚ Noridian Mutual Insurance Company Web Site Address: http://www.noridianmedicare.com/ Local Medical Review Policy for Chiropractic: (NOTE THAT THIS IS CURRENTLY THE DRAFT LMRP. This will be finalized in the near future) http://www.noridianmedicare.com/provider/cmd/draftb/Chiro98940-4.html ABN Form Information Page 1