Coding Questions: Medicare maintenance claims and the new ABN form

Published: 2009-08-03 00:13:42
Author: Marty Kotlar | Chiropractic Economics | September, 2008

Q: With the current Advanced Beneficiary Notice (ABN) form, I have to submit claims for maintenance care even though it’s not payable by Medicare if the patient checks “yes” to option No. 1. Does the new ABN form allow me to discontinue submitting claims to Medicare for maintenance care?

A: The ABN informs a Medicare patient 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 patient to make an informed consumer decision about whether or not to receive the item or service for which he or she may have to pay for through other insurance or out of pocket.

As of Monday, March 3, 2008, chiropractors may use the new ABN form for all situations where Medicare payment is expected to be denied. The new ABN form CMS-R-131 (03/08), called the Advanced Beneficiary Notice of Non-Coverage, replaces ABN Form CMS-R-131-G (June 2002), ABN-L Form CMS-R-131-L, and NEMB Form CMS-20007 (January 2003).

CMS will allow a six-month transition period from the date of implementation for use of the revised form and instructions. Thus, all providers and suppliers must use the ABN Form CMS-R-131 (03/08) by Sept. 1, 2008.

So, do you have to continue to submit your claims to Medicare for maintenance care? It depends which option box the patient chooses. The new ABN form has 10 customizable areas labeled (A) through (J). Area (G), the “options box,” must be completed by the patient or his or her representative. This options box has three choices:

• OPTION 1. I want the “Chiropractic Maintenance Care” listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN).

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