Medicare Specific Billing Requirements
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Medicare: Specific Billing Requirements

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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."

Covered Services

In the view of CMS, covered chiropractic services are limited to treatment by means of manual manipulation of the spine to correct a subluxation.

Direct Billing

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.

Discounts

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.

Limits

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.

Limiting Charge

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.

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.

Medigap

Medicare Supplemental Insurance, which is known as Medigap was developed for the specific purpose of filling in the payment "gaps" in the original Medicare program. Medigap insurance only applies to Part B Medicare, not Medicare Advantage. Depending on the type of Medigap insurance a beneficiary may have, the policy could pay for most, if not all, of the coinsurance and deductibles of Medicare covered services. Medigap policies generally do not cover Medicare non-covered services. 

Non-covered Services

In CMS's view, non-covered chiropractic services are any professional services rendered other than manual manipulation of the spine to correct a subluxation. These are examinations, x-rays, and physical therapy modalities, etc. In order to make your collections for non-covered services compliant, either from the Medicare patient or supplemental carriers, if the insurance will pay for non-covered services, a new modifier should be used for all the Medicare carriers on a national basis. On the EOMB next to the denial of payment "PR" will be designated next to that charge, and the payment is then the "Patients Responsibility." This code should be used for examinations, therapies, and all services except spinal adjustments, as limited by present statute and not covered by Medicare for payment.

Primary/Secondary

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.

Replacement Doctor

When you need to leave your office for an extended number of days, requiring you to bring in another doctor to treat patients, the regular treating physician should be listed as the doctor in box 31 on the CMS-1500 form. However, Medicare does require that you append modifier Q6, which indicates the service was provided by a “locum tenens” physician. Per CMS, the following criteria must be met in order for the replacement physician to qualify for “locum tenens”:

  • The regular physician is unavailable to provide the service.
  • The beneficiary has arranged or seeks to receive the services from the regular physician.
  • The locum tenens is NOT an employee of the regular physician.
  • The regular physician pays the locum tenens physician on a per diem or fee-for-service basis.
  • The locum tenens physician does not provide services to beneficiaries over a continuous 60-day period.
  • The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished by a locum tenens physician) after the procedure code.

X-Rays

In a final rule released in November 2007, CMS eliminated the exception previously held by doctors of chiropractic that allowed them to refer patients to a "non-treating physician" such as a radiologist and have the patient receive reimbursement for the X-rays taken. DCs may still refer the patient back to a treating physician, such as a primary care physician, and X-rays ordered should be reimbursed. The thing to remember is that even though the laws in your state might permit you to order X-rays and other services or tests, Medicare providers may not be reimbursed for performing them from your order. To ensure that all providers are reimbursed for X-rays that you use in patient care, you should refer the beneficiary to a MD or DO, who would then order the X-ray. The billing entity would then enter the MD/DO name and UPIN on the claim (Box 17) as the ordering physician. If using an x-ray to document the subluxation under Medicare, rather than the P.A.R.T. process, it must be taken at a time reasonably proximate to the initiation of care. This is generally taken to be 12 months prior to or 3 months following the beginning of chiropractic treatment. Usually an X-ray date should be indicated in Box 19 for the CMS-1500 Form. Your local carrier will specify. Some carriers still require the precise level of subluxation in this box. Carriers may, at their discretion, deem that an older x-ray may be acceptable if the beneficiary's health record indicates the condition has lasted longer than 12 months and there is a reasonable basis for concluding the condition is permanent.

Questions? Contact ACA.