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Tuesday, July 10, 2012

ABN Option #2 ~ Newsletter 7/2/2012

NewsletterJuly 2, 2012Chiropractic MedicareABN Option #2

Since posting my prior newsletters about ABN there has been considerable interests and questions  in regard to Option #2.

Option #2 on the ABN states, "I want the (Blank) listed above, but do not bill Medicare.  You may be asked to be paid now as I am responsible for payment.  I cannot appeal if Medicare is not billed.”

Option #2 is for ONLY non-covered services.

The Chiropractic adjustment is the only covered service for Chiropractors.

 National Government Services issued a "What's New" article on 6/27/12 with their explanation of the understanding of Option #2 as follows:

1. Option #2 of the ABN is to be used when a Chiropractor is providing a service to a Medicare beneficiary that is not going to be covered by Medicare.  The confusion has come in from some that believe Option 2 can only be utilized by the Chiropractor for the patient when the service is statutorily non-covered.  However, that is not the case.
2. The description for Option #2 indicates that the provider has told the beneficiary that Medicare will not cover the service because it does not meet policy criteria; therefore, it will be a non-covered service.  By selecting Option #2 the patient is authorizing that they still want the service to be performed and that they will pay the practitioner for the service.  Option #2 also alerts the beneficiary that a claim will not be filed to Medicare and that they have no appeal options.

3. The misunderstanding is that since the Chiropractic service is a Medicare benefit, just not covered for this specific scenario, that Option #2 should not be used.  The belief is that the Chiropractic adjustment is always a covered service; however it is not always covered, it is simply recognized as a Medicare benefit.  This also leads to the misunderstanding that Chiropractic adjustments must always be billed to the Medicare carrier for consideration.  With the implementation of the new ABN form, this is no longer the case.  Providers are allowed to provide a service to a beneficiary that they know will be non-covered by Medicare according to policy and 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.
4. The Centers of Medicare & Medicaid Services (CMS) Internet-only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.14.1 (1.07 MB) states that in this situation the provider will not be violating "Mandatory Claim Submission" guidelines:

"Note:  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."

If this is true, now the patient has the authority to mark Option #2 and it supersedes "Mandatory Claims Submission" and the "Participating Provider Contract" of not collecting the 80% of the fees at time of visit.  This also denies the patient from reimbursement for the covered service of the adjustment.  It also is another way cut Chiropractic reimbursement.

I am awaiting official explanation from CMS that I shall share as quickly as I receive.

Remember, we all must become Medicare Compliant by the end of this year!

Have questions? Give Dr. Street a call today at (618) 395-3800.

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Keep in mind, Medicare is the only insurance type program that if done incorrectly is fraud, a felony, a fine and/or jail.

Resources and further reading:

NGS pdf document  "869c_910_Notices_of_Noncoverage.pdf"


  1. Dr. Street

    Your knowledge in invaluable as the Contractors continue to mass audit us. I see no end in sight. You bring up a very good point about ABN #2 here. As CMS says you do not have to bill with option 2 checked, how can this override a federal ruling? Good question!

  2. Thanks for your comment. If you would like to discuss give me a call. I'm sorry I took so long to respond!


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