In perhaps what many would consider a rare moment of clarity, NGS (the Part B Medicare carrier) issued a statement recently to clarify some confusion on the use of the ABN for chiropractic services.  Whether or not NGS is your carrier, this article can serve as a helpful reminder to make sure you are using the ABN properly in your office.

Specifically, the NGS press release focused on three common pieces of misinformation they see with respect to chiropractors’ usage of the ABN form.  In virtually every seminar I present — regardless of the location — there is much confusion about how to use the Medicare ABN properly so I would agree that this are necessary reminders. In brief, here they are:

Misinformation #1:  Chiropractic Spinal Manipulation is always a reimbursable service in Medicare.

Reality #1:  The chiropractic adjustment is a covered service but it is payable only IF the CMT meets medical necessity!  This is an important distinction and can potentially affect your reimbursement, how you charge your patient and whether or not the ABN is used.

“When a Medicare covered service (such as the chiropractic adjustment) is NOT deemed medically necessary and payable by Medicare, the provider is required to issue an ABN prior to the services being rendered, so that the beneficiary can make an informed consumer decision as whether or not they want to receive the services.” (emphasis mine).

When issuing an ABN, the beneficiary has three options available on whether or not to receive the services and whether Medicare is to be billed. The beneficiary must make the selection and not the provider.  Option 1 requires you to bill the non-payable service anyway.

Misinformation #2:  Option 2 of the ABN can only be utilized by the chiropractor for the patient when the service is statutorily noncovered, (i.e., massage, x-rays, etc).

Reality #2: You are required to give the beneficiary (your Medicare patient) an ABN if it is believed that the covered services (chiropractic adjustment) will likely not be paid by Medicare based on medical necessity.

The ABN also serves as an optional notice to forewarn beneficiaries of their financial liability prior to providing care that Medicare never covers. Service such as x-ray, labs, massage, evaluation & management, and EMGs, are never covered by Medicare when performed by a chiropractor. The ABN can be used voluntarily to notify the beneficiary that Medicare will not pay for these services. (Underlining for emphasis, mine)

Misinformation #3: Chiropractic adjustments must always be billed to the Medicare carrier for consideration.

This is perhaps one of the most misunderstood features of the ABN and one that can definitely save you a lot of time and trouble — if you understand how to properly take advantage of it.

Option 2 on the ABN form states that the beneficiary wants to receive the item or services at issue and will accept financial responsibility.  When signing Option 2, the patient also gives the provider the permission to NOT submit a claim to Medicare at the beneficiary’s request. Because no claim is filed, there are no appeal rights when the beneficiary chooses this option.

With the implementation of the new ABN form, providers are allowed to provide a service to a beneficiary that they know will be noncovered by Medicare (i.e. a maintenance spinal adjustment). According to Medicare policy, the patient has the right to still have that service, pay the provider for that service and waive the filing of a claim to Medicare.  (italics mine for emphasis)

For those of you who think that this may almost sound too good to be true, note the following which is from the

Chapter 30, Section 50.14.1 of the Medicare Claims Processing Manual  states that in this situation the provider will not be violating “Mandatory Claim Submission” guidelines with the following:

“Providers will not violate mandatory claims submission rules under Section 1848 of the Social Security Act when a claim is not submitted to Medicare at the beneficiary’s written request in choosing Option 2 on the revised ABN.”

Summary

As I have stated before on multiple occasions, chiropractors are required to submit claims to Medicare.  We have no ability to opt out of the Medicare system.  If you are simply “not doing” Medicare, you are not doing something right — watch out!  But for those of us who understand the rules and regulations, there are ways to legally minimize our hassles and still get paid for what we do.  The ABN is a good example.  Keep up the good work!

(Click  ABN Option 2 and Chiropractic Billing Clarifications if you want to read the full article issued by NGS.)