General Questions and Answers about the Medicare Program

If this FAQ does not answer your question:
  • You can purchase the ACA Clinical Documentation Manual or the ACA Chiropractic Coding Solutions Manual, which has an individual section addressing Medicare.
  • Explore the ACA Medicare website.
  • You can consult this FAQ on the Centers for Medicare and Medicaid Services (CMS) website.
  • If you are an ACA member, you can call the ACA office at 1-800-986-4636 or email us your question at memberinfo@acatoday.com. Not a member? Click here.



    Activator (usage of)

    Q: I have heard differing answers as to if it is appropriate to bill Medicare care for the use of an Activator type device when performing manipulation. Could you tell me if I am allowed to use an Activator?
    A: Yes, you may use an Activator type device. According to the Medicare Carrier Manual, "Manual Manipulation-Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize and extra charge for the device itself."



    Acupuncture

    Q: I have heard that CMS has published relative values for the new acupuncture codes. Does this mean that Medicare will now reimburse us for these procedures?
    A: No. Acupuncture services are still a non-covered benefit for Medicare patients, regardless of the provider type billing them. However, it is important to remember that, for the purposes of secondary billing, you must bill the new acupuncture codes, 97810, 97811, 97813 and 97814. Medicare no longer allows a ninety-day grace period for providers to use discontinued codes, and the use of the old/deleted acupuncture codes of 97780 and 97781could cause delays in your claim being processed. For a complete description of the new acupuncture codes and their proper billing, please see the Coding Q&A in this issue of ACA News, or go to: http://www.acatoday.com/content_css.cfm?CID=986

    Lastly, remember to append the GY modifier to the acupuncture codes to indicate that the service is statutorily non-covered.

    See also: Therapy Services



    Advance Beneficiary Notice (ABN) 

    Q: What is an Advance Beneficiary Notice (ABN) and what does one look like?
    A: An ABN is a written notice a doctor of chiropractic must give to a Medicare patient before CMT services are provided when the doctor believes these services will likely be denied by Medicare. The doctor must notify the beneficiary before the services are furnished that, in his/her opinion, the patient will be personally and fully responsible for payment. The ABN must be signed each time the doctor believes Medicare payment probably or certainly will not be made. 

    An ABN has been released by CMS for doctors to copy and use in their offices. A brief outline of what must be included on an ABN is listed below, but for a sample copy visit the ACA website.

    The notice must include the service you expect will not be covered. B) A single ABN covering extended course of treatment is acceptable provided the ABN identifies all services for which the doctor believes Medicare will not pay. For example, chiropractic services often are furnished under and extended course of treatment. If, as the extended course of treatment progresses, additional items or services are to be furnished for which the physician or supplier believes Medicare will not pay, the physician or supplier must separately notify the patient in writing (give the beneficiary another ABN) that Medicare is not likely to pay for the additional items or services and obtain the beneficiary's signature on the ABN. One year is the limit for use of a single ABN for an extended course of treatment; if the course of treatment extends beyond one year, a new ABN is required for the remainder of the course of treatment C) The patient must sign and date for each visit, indicating whether they will go forward and accept the services and be financially responsible, or whether they decline to have the services rendered.

    For CMS instructions on completing the most recent ABN (released March 3,2008) click here.
    For further information visit the ABN portion of the ACA website.


    Q: ACA has previously suggested that the ABN form is used to notify the beneficiary that the "normally covered item or service they are about to receive that day may not be paid for by Medicare....etc," or in other words, for CMT, as this is the only procedure Medicare reimburses to doctors of chiropractic. However, we have been informed through a different source that there is another ABN form for laboratory tests (form No CMS-R-131-L), which requires a physician to obtain a beneficiary's signature before ordering lab tests. Could you please tell me why there is a discrepancy between the two opposing views I've heard?
    A: One article in ACA Today does indeed state, "For doctors of chiropractic, the only item or service that should ever appear on an ABN is spinal manipulation." While there is another ABN form for laboratory tests, which is separate from the "general use" form, a doctor of chiropractic is not required to obtain an ABN signature for laboratory tests. The sole reason is that a laboratory test is not a "normally covered item or service" reimbursed by Medicare to doctors of chiropractic.






    Appeals

    Q: I do not have the time to do all it takes to appeal every Medicare claim. Is there an easier way?
    A: Since February 1, 2000, providers and beneficiaries, who are entitled to appeal Medicare Part B Initial Claims Determinations have been permitted to request reviews by telephone. The final rule also permits carriers to conduct the review by telephone, if possible. The use of telephone requests supplements, but does not replace, the written procedures for initiating appeals. This telephone option improves carrier relationships with the providers and beneficiaries by providing quick and easy access to the appeals process. Dr. Jerry Gerrard, former chairman of the ACA's Medicare Committee, agrees. "Many times it's difficult to properly explain a problem or condition in writing. Having telephone access to the appeals process allows the provider to discuss the issues and the other party to receive a detailed explanation. They are more likely to understand the need for care when it can be discussed person to person."



    Billing

    Q: Are we allowed to bill Medicare patients directly (i.e. not billing Medicare) as long as we have the patient's consent in writing?
    A: No. If a doctor of chiropractic performs a spinal manipulation to a Medicare beneficiary, Medicare must be billed for the service. Period. This includes both participating and non-participating doctors, and it includes both active (acute/chronic) and maintenance care.

    See also: CMS 1500/Box 32, Diagnostic/ICD9 Codes, Medicare as Primary/Secondary, X-Rays



    CMS 1500

    Q. My carrier recently sent a notification to me stating that we now must include our office information in Box 32 on the CMS-1500 form. We have always followed the instruction in the box that indicates it need be filled out only if the service is rendered somewhere other than office or home. Would you please clarify?
    A: Your carrier is correct. The information contained below is directly from CMS, and clearly shows that your business name and mailing information must now be in Box 32.

    "Effective for claims received on and after April 1, 2004, all Medicare Part B claims must contain the name, street address, and zip code where the service was rendered in block 32 of the CMS 1500 claim form. Failure to report this information in block 32 will result in the claim being returned as unprocessable and you will not be afforded appeal rights.

    Please note: Even if you are reporting a service in your office you must report this information in block 32. Please disregard the CMS 1500 claim form instructions for this block, which tell you to report name and address of facility where services were rendered if other than home or office."

    For more information: http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf

    See also: Replacement Doctor



    Covered services/non-covered services

    Q: What is a covered chiropractic service?
    A: In the view of CMS, covered chiropractic services are limited to treatment by means of manual manipulation of the spine to correct a subluxation.

    See also: Non-covered Services, Demonstration Project



    Deductible

    See Participating Provider (par).



    Demonstration Project

    See Medicare Regulatory Information



    Denials

    See also: Appeals, Modifiers, CMS 1500, Diagnostic/ICD9 Codes, Electrical Stimulation, Acupuncture, Hot/Cold Packs, Limits (visits).



    Diagnostic/ICD9 Codes

    Q: I have recently received a memorandum from my carrier stating that I should now use the 739 series ICD-9 codes as opposed to the 839 series. Is this a new CMS policy, and if so, will it have any affect on reimbursement of CMT procedures?
    A: There is no new CMS policy on this issue; rather, it is a carrier specific requirement. The majority of carriers prefer the 739 ICD-9 series, which describes lesions, as opposed to the 839 ICD-9 series, which describes dislocations. A carrier requiring this as part of its Local Medical Review Policy (LMRP) does nothing in the way of altering reimbursement amounts, and does not in any way affect other guidelines associated with reimbursement of CMT procedures under Medicare.



    Discounts

    Q: I would like to offer cash discounts to Medicare patients. Is this ok?
    A: Offering a cash discount to Medicare beneficiaries is problematic under federal anti-kickback laws. On the Office of Inspector General website there is a special fraud alert called Routine Waiver of Co-payments of Deductibles Under Medicare Part B, 59 Federal Register at 65374. It is very helpful.



    Electrical Stimulation

    Q: I have heard very conflicting reports with regard to billing for electrical stimulation under Medicare. I have heard that I should report CPT Code 97014-GY as usual, yet I have also heard I need to begin billing with HCPCS Code G0283. Would you please tell me which is the proper code to report when billing for electrical stimulation under Medicare?
    A: Effective January 1, 2003, CPT code 97014-application of a modality to one or more areas; electrical stimulation (unattended)-was assigned a "status indicator" of "I" on the Medicare Physician Fee Schedule Database. This means that this code is considered "not valid" for Medicare billing purposes because Medicare uses another code for the reporting of this service. Therefore, when billing Medicare for electrical stimulation, HCPCS code G0283-electrical stimulation, other than wound care, as a part of a therapy plan-should be utilized. Of course, the -GY modifier will still need to be attached.



    Fee Schedule

  • ACA Medicare Physician Fee Schedule Webpage



    Fraud

    See Discounts.



    Hot/Cold Packs

    Q: Can I charge CPT code 97010, Hot/Cold Packs, to a Medicare patient?
    A: Medicare considers CPT Code 97010, Hot/Cold packs a "bundled" services. This means that it's not a separately billable service. It will be considered a part of whatever primary service is rendered to the patient on that visit. For doctors of chiropractic, that will be the CMT codes, 98940-98942. Please note, this differs from a "non-covered" service. A non-covered service can be charged to the patient. A bundled service cannot be charged to the patient.



    Limits (visits)

    Q: I keep hearing of a 12-visit limit under Medicare where, after a patient has received 12 visits within a year, the claims are all denied. I've noticed this in my practice as well. I was under the impression that CMS disallows caps on chiropractic services, provided all documentation and necessity issues are met. Could you please clarify?
    A: You are correct in that CMS disallows caps of any kind on chiropractic care, as long as all documentation and necessity criteria are met. If you are noticing a trend where there seems to be a routine denial of care after 12 visits (or 18, or any other arbitrary number), the only way to gain the rightful reimbursement is to appeal the claim(s). This not only will allow the doctor to get paid for services he/she rendered but, more importantly, it will prevent the beneficiary from having to pay out-of-pocket for a benefit to which they are entitled.

    If you are unfamiliar with appealing Medicare claims, there is a Medicare Appeals section in the ACA's Chiropractic Coding Solutions Manual.  For more information, click here


    Limiting charge

    Q: What is a limiting charge?
    A: Those health care providers who do not accept assignment are prohibited from charging more than 115% over Medicare's approved payment amount. The amount that the nonparticipating practitioner is permitted to charge a Medicare beneficiary is referred to as a limiting charge. Limiting charge amounts are provided annually to providers. Doctors are allowed to round the limiting charge to the nearest dollar as long as all services are rounded consistently.

    See also: Participating Provider (par), Non-participating Provider (non-par)r



    Local Policy

    Q: How Do I keep Current With Local Medicare Contractor Policy?
    A: Contact the local Medicare contractor and request the most recent chiropractic policy. This policy should have appeared in a Medicare news brief or newsletter. Whenever one of these Medicare newsletters is received in your office, carefully read all the Table of Contents and look for items relating to policy (chiropractic) and refer to that item. It is wise to save all articles that refer to chiropractic appearing in these periodicals and follow the guidelines listed in the chiropractic policy. Keep your insurance and billing staff updated on these policies, as they change frequently.  To locate your contractor, click here.



    Maintenance Care

    Q.  Should I report S8990 (“Physical or manipulative therapy performed for maintenance rather than restoration) to Medicare for maintenance manipulation?                                                                                                                           A.  NO.   S-codes, including S8990, were developed for use in the private sector only—they were never intended for use with Medicare.  Using non-standard Medicare coding could raise a red flag with your contractor.  When reporting maintenance chiropractic manipulative treatment to a CMS contractor (Medicare), use codes 98940-98943 without an AT modifier. 


    See also Advanced Beneficiary Notice (ABN).



    Medicare

    Q: What is the Original Medicare Plan?
    A: Traditional Medicare is the federally sponsored fee-for-service health insurance program for people 65 years of age or older and certain younger people with disabilities. Medicare beneficiaries may choose the services of any care provider whose services are recognized by Medicare. Traditional Medicare has two Parts: (A) hospital insurance and (B) general medical insurance. Currently Medicare recognizes chiropractic services, i.e., treatment by means of manual manipulation of the spine to correct a subluxation, as a reimbursable Part B benefit.



    Medicare+Choice

    What is Medicare Advantage?

    Medicare Advantage was created in 1997 to provide beneficiaries with a greater selection of Medicare health care options, specifically through Medicare managed care organizations. Medicare Advantage organizations are mandated by law to provide beneficiaries with all Part A and B benefits and services.



    Medicare as Primary/Secondary

    Q: I thought Medicare was always primary. How do you determine if Medicare is primary or secondary?
    A: If an individual or his/her spouse is currently employed and covered under an employer group health plan as a result of current employment, then Medicare is secondary. Additionally, the employer must have 20 or more employees or be participants in a multiple/multi-group health plan where at least one employer has 20 or more employees. If the individual in question is entitled to Medicare as a result of disability, the company must have 100 or more employees or be participants in a multi/multiple group health plan where one employer has 100 or more employees. If the individual in question is Medicare entitled due to end stage renal disease, Medicare is the secondary payer to a group health plan until a 30-month coordination period has ended.

    Q: I recently had a Medicare beneficiary come in for an auto accident related injury. Am I required to bill Medicare after the normal 120-day wait period, even if I'm paid in full by the auto carrier responsible for payment?
    A: No. If the auto carrier pays you in full, you are not required to bill Medicare. However, if you were not paid in full, you would bill Medicare with a copy of the EOB from the auto carrier. The 120-day wait period really does not apply in this instance.

    If you bill the auto insurer, and there is no payment forthcoming within 120 days, you then have the option of billing Medicare as primary. This would require you to send a copy of the denial or "pending" notice to your Medicare carrier along with the bill. If you chose to do this, you must accept payment as you would with a "regular" Medicare patient and relinquish all rights/liens to the auto payment/settlement.


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