Medicare: Specific Coding Requirements

Medicare is very specific about coding. Below are some commonly used by doctors of chiropractic (DCs).

Acupuncture

Even though CMS has published relative values for the new acupuncture codes, 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 97781 could cause delays in your claim being processed. Remember to append the GY modifier to the acupuncture codes to indicate that the service is statutorily non-covered.

Electrical Stimulation

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.

Hot/Cold Packs

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.

Maintenance Care

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. 

Therapy Services

As of September 1, 2003 there is a requirement for most therapy services when billed to Medicare by doctors of chiropractic. Both a GP and a GY modifier will now need to be appended to most therapy codes on all claim submissions, effective for dates of service on and after July 1, 2003 (Examples: 97012-GPGY, 97035-GPGY, G0283-GPGY, 97124-GPGY).

There are two lists of codes that would affect chiropractors. The first list requires the use of the GP modifier on all claim submissions (there must also be a plan of care on file for these outpatient therapy services*). The second list requires the use of the GP modifier only under certain conditions.

Chiropractors will not be reimbursed for these services; however, failure to include the GP modifier for these services will result in the claim/service being returned as unprocessable.

Codes that always require the GP modifier and an appropriate plan of care include:
92506 92507 92508 92526 92597 92607 92608 92609 97001 97002 97003 97004 97012 97016 97018 97020 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97504 97520 97530 97532 97533 97535 97537 97542 97703 97750 97799 V5362 V5363 V5364 G0281 G0283

Physicians must also use the GP modifier with the codes below when the services are provided under a therapy plan of care:
29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29220 29240 29260 29280 29345 29355 29365 29405 29425 29445 29505 29515 29520 29530 29540 29550 29580 29590 64550 90901 90911 92610 92611 92612 92614 92616 95831 95832 95833 95834 95851 95852 96000 96001 96002 96003 96105 96110 96111 96115 97601 G0279 G0280 0020T 0029T

Therapy services, no matter who performs them, must meet the standards and conditions that apply to therapy services. For example, there must be an appropriate plan of care and documentation that supports medical necessity whenever therapy services are billed to Medicare.

Questions? Contact ACA.