Then, let's say after 15 visits, the patient becomes stable but they say, "It just feels so good. I love to come once a week." That's where you use an ABN. What an ABN is for is it's an Advance Beneficiary Notice. In other words, in advance of the treatment that patient signs a notice where they understand the service is not covered. This is for maintenance. If you sign it at the beginning, how could they sign a form where you say, "Well, I don't know if it's going to be covered?" The doctor actually has to make a decision do you believe the service to be corrective or not corrective. If it's corrective, it's not appropriate to sign an ABN because what you're saying is, "Well, it's not corrective." You really have to make that choice. When it does reach a point where you believe its maintenance are not covered and that's really the doctor's choice is after 12, 15 whatever the patient then fills out the form or the doctor does and the patient signs. What the form explains is that Medicare is not going to cover manipulation and you'll explain because Medicare won't cover for these many visits for your condition. Medicare will consider it as maintenance. As long as you put something on it that the patient is understanding its maintenance or not covered, the patient then has a choice. The patient signs in and says, "Okay. I understand it's not covered but I want you to bill Medicare anyway." That's option 1 which means the doctor has to bill Medicare even though Medicare is automatically going to deny it, the patient has the option. Then, there's option 2 where the patient says I want the services but do not bill Medicare. For most chiropractors, that's the one we will prefer because actually, when a patient signs option 2, you actually don't have to bill Medicare. Now, that doesn't mean the patient gets the visit free. They pay you the same as they would any other time but it's just the patient paying upfront. There is a third option that says I don't want the service which is okay because the person's going to say, "I can't afford it." What doctors have to understand is Medicare will look in your file to make sure if your care was not medically necessary and you didn't have the patient sign an Advance Beneficiary Notice, the care is denied and you can't collect from the patient. What you can't do is a blanket ABN at the beginning saying, "I don't know what Medicare is going to do." You have to have some reasonable timeframe in your mind. My rule is to take a look at the Medicare diagnosis. In most states, Medicare puts the secondary diagnosis in categories 1, 2, and 3 which is short, moderate and long-term care. If you're using a short-term diagnosis, I would have the patient sign an ABN probably about the 12th visit because Medicare won't likely cover much more than that or if it's a moderate-term, maybe about the 20th visit and so on. The key is making sure that we protect ourselves that if the care is maintenance that the patient indicates it. Now, to bring it back full circle, it is okay that a doctor uses an ABN for non- covered services. You cannot put non-covered service and coverage service on the same ABN because there's different answers. If you're going to use one at the beginning, that's fine but that would be for the services Medicare never covers meaning everything but spine manipulation. Then, the point that it becomes not medically necessary or maintenance that's the time when the provider would have to do another ABN specifically for those. When you've done an ABN, you bill the manipulation with modifier GA and that's an automatic
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