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Auxilary Aids & Services

For information about the availability of auxiliary aids and services, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

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Railroad Medicare
Advance Beneficiary Notice of Non-coverage (ABN) for Chiropractic Use

The revised CMS Advance Beneficiary Notice of Non-coverage (ABN) (Form CMS-R-131) was mandated for use. This version incorporates the previous versions, ABN-G (for general use) and ABN-L (for laboratory use), and the Notice of Exclusion from Medicare Benefits (NEMB) into a single notice. The dual purposes of the revised ABN are further explained below.

Medical Necessity
The purpose of the revised ABN is still to give notice to Medicare patients with traditional Medicare that Medicare is likely to deny a service based on medical necessity guidelines. This scenario applies to chiropractic manipulative treatment that no longer provides functional improvement and is considered to be maintenance therapy. HCPCS modifier GA is used to indicate that a signed ABN is on file. The service will be denied, and the patient will be financially liable.

Reminder:
If the beneficiary selects option one, he/she is agreeing to pay out of pocket for the service in question and requests that the chiropractor file a claim for that service with Medicare. With option one selected, the beneficiary retains appeals rights if s/he disagrees with Medicare’s claim decision. The chiropractor is permitted to ask for payment from the beneficiary.

If a beneficiary selects option two when he/she agrees to pay out of pocket for the service in question and does not want a claim sent to Medicare. In accordance with the ABN, the provider would not file a claim, and the beneficiary would not have appeal rights since no claim is being submitted. (Please note that the patient can change his/her mind at a future time and request the claim be submitted.)

If a beneficiary selects option three he/she chooses not to receive and pay for the service. No service is rendered, and no claim is filed. Since no claim is filed, the patient cannot appeal to Medicare for a payment decision.

Statutorily Excluded Services
The CMS Notice of Exclusion from Medicare Benefits (NEMB) is no longer available. The revised ABN is also used in place of NEMB on a voluntary basis. While not mandated, the ABN may be provided to Medicare patients as a courtesy, to inform them of their financial responsibility for services that are statutorily excluded from Medicare benefits. Statutorily excluded services are services that, by law, Medicare cannot pay for. This includes any service provided by a chiropractor other than manual manipulation (e.g., evaluation and management (E/M) services, physical therapy, nutritional supplements and counseling).

Generally, providers are not required to submit claims to Medicare for statutorily excluded services. There are times, however, when the patient requests these services be submitted in order to obtain a denial for secondary insurance purposes. In this case, submit statutorily excluded services with HCPCS modifier GY.

Other Applicable Modifiers
The following are additional modifiers that may be submitted on chiropractic claims:

HCPCS ModifierDescriptionApplicable Codes
AT
Active/corrective manual manipulation was provided to treat an acute or chronic subluxation
CPT codes 98940, 98941 and 98942
(Not to be used with maintenance therapy)
GP
Services were delivered under an outpatient physical therapy plan of care
Physical therapy services
(CPT codes 97001 – 97546)
GZ Service(s) expected to be denied as not reasonable and necessary and an Advance Beneficiary Notice (ABN) has not been signed by the beneficiary Part A and Part B services

The following are examples of when it is appropriate to ask the patient to sign an ABN:

Service ProvidedCPT CodeHCPCS Modifier
Evaluation & Management Service
99XXX GY
X-ray of the spine
7XXXX GY
Therapeutic procedure
97XXX GP and GY
Maintenance therapy
989XX GA*

*Include when there is a valid Advance Beneficiary Notice (ABN) on file for the service

Note: The use of any modifier must be supported in the patient’s medical record.

Reference:


 

last updated on 04/15/2014
ver 1.0.51