The Advance Beneficiary Notice of Noncoverage (ABN) — CMS form CMS-R-131 — is one of the most important compliance documents in a chiropractic practice that treats Medicare patients. When used correctly, it protects both the patient and the practice. When skipped or used incorrectly, it can cost you thousands of dollars in unrecoverable charges.
What Is an ABN?
An ABN is a written notice you give to a Medicare patient before providing a service that Medicare may not pay for. It informs the patient that Medicare may deny the claim, explains why, states the estimated cost, and gives the patient the choice to receive the service and accept financial responsibility, or to decline the service.
The ABN is not optional — it is required by CMS whenever you have reason to believe Medicare will not cover a specific service for a specific patient.
When Chiropractors Must Use an ABN
In chiropractic practice, ABN situations arise frequently. The most common scenarios include:
Transition to Maintenance Care
This is the single most important ABN situation for chiropractors. When a patient reaches maximum therapeutic benefit (MTB) and you plan to continue treatment as maintenance care, you must issue an ABN before the first maintenance visit. The ABN should state that Medicare considers further treatment to be maintenance (not active treatment) and that the patient will be responsible for the full cost.
Non-Covered Services
Medicare does not cover many common chiropractic services including X-rays (when ordered and billed by the chiropractor), E/M visits and examinations, therapeutic modalities (ultrasound, electrical stimulation, hot/cold packs), therapeutic exercise and rehabilitation, and extraspinal (extremity) manipulation. If you provide any of these services to a Medicare patient, an ABN must be signed before each service is rendered.
Frequency Concerns
If you believe Medicare may deny a visit due to frequency (for example, the patient is being seen more often than typical for their condition), an ABN should be provided. This is a judgment call — but when in doubt, issue the ABN.
Critical rule: The ABN must be given before the service is provided — not after. An ABN signed after the service has been rendered is invalid, and you cannot bill the patient for the denied service. Train your front desk to handle ABNs before the patient enters the treatment room.
How to Fill Out the ABN Correctly
The ABN (form CMS-R-131) has specific requirements. Key fields include:
- Notifier — your practice name, address, and NPI
- Patient name — printed legibly
- Items or services — describe the specific service that may not be covered (e.g., "chiropractic maintenance therapy — spinal manipulation" or "diagnostic X-ray, lumbar spine")
- Reason Medicare may not pay — state the specific reason clearly (e.g., "Medicare does not cover chiropractic care once maximum therapeutic benefit has been reached" or "Medicare does not cover X-rays when ordered by a chiropractor")
- Estimated cost — a good-faith estimate of what the patient will owe. CMS requires a specific dollar amount or a reasonable range — not "whatever Medicare doesn't cover"
- Patient's choice — three checkbox options allowing the patient to choose whether to receive the service and accept financial responsibility
- Signature and date — the patient must sign and date the form before the service is provided
What Happens Without an ABN
If you provide a service that Medicare denies and you did not have a valid ABN on file, the financial consequences are clear: you cannot bill the patient. You must absorb the cost of the denied service entirely. This applies regardless of whether the patient was willing to pay — without the ABN, CMS prohibits you from collecting.
For practices that routinely provide maintenance care or non-covered services to Medicare patients without ABNs, the financial exposure can be substantial. If an audit reveals a pattern of denied claims without ABNs, the repayment demand can cover months or years of services.
ABN Best Practices for Chiropractic Offices
- Create standard ABN templates for your most common scenarios — maintenance care transition, X-rays, modalities — so they can be quickly customized and presented
- Train front desk staff to recognize ABN triggers and present the form before the patient goes back for treatment
- File signed ABNs in the patient's chart where they can be retrieved quickly in case of an audit
- Review ABN expiration — an ABN covers a specific service or time period. For ongoing maintenance care, consider having the patient sign a new ABN every 6-12 months to ensure continued validity
- Use the current form version — CMS periodically updates the ABN form. Using an outdated version can invalidate the notice
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Subscribe — $247/month →The Bottom Line
The ABN is a financial protection tool — for both your patients and your practice. The few minutes it takes to present and sign an ABN before a non-covered service can save your practice thousands of dollars in unrecoverable charges. Make it a non-negotiable part of your Medicare workflow, and treat any service you have reason to believe Medicare may deny as an ABN situation until you are certain otherwise.