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Wednesday, March 30, 2011

Who is responsible for Chiropractic Medicare Coverage?

Fellow chiropractors…. Please lend me your ears, eyes, and Chiropractic Medicare Commitment!

To my knowledge, Medicare is the only health care reimbursement program that recognizes and has a specific accurate chiropractic understanding. The chiropractors in the early seventies that wrote the chiropractic Medicare Guidelines did it correctly. They worked hard for us to have the privilege to be providers in Medicare and to assure that seniors also had the privilege of Medicare reimbursement for freedom of choice. Yes, chiropractic Medicare is a privilege and 98.6% of all Chiropractors do receive Medicare reimbursement for correcting vertebral subluxations. I agree, the reimbursement is not the dollar value of the adjustment, but many chiropractic practices across America receive large sums of dollars from Medicare.
You may be upset Medicare does not pay for other services by chiropractors, but the non-coverage of x-rays and exams are our fault…. not Medicare. One of our national Chiropractic associations decided we did not need x-rays. And then came the Demonstration Project. A test program by the government to see if we Chiropractors could save Social Security money. This project took place in Scott County, IA. 33 counties in Northern Illinois, Maine, New Mexico and 33 counties in West Virginia. All services by a Chiropractor were reimbursed by Medicare. X-rays, exams, therapy, referrals for MRI’s, CT scans, etc. The result is devastating. Every State EXCEPT ILLINOIS showed zero cost factor…. costing the Medicare program nothing. The Chiropractors in Illinois racked up the bills so much….The Demonstration Project was a MAJOR failure.  Even worse…. The Inspector General said they want money back and implemented audits on the entire Chiropractic Medicare providers.
The last Inspector General’s Report indicated that out of 100 claims filed by Chiropractors, 68% have errors and were inappropriately paid. Again… they want the money back. Presently New York State and two other states have pre-payment reviews on ALL claims billed to their Medicare carrier. The Inspector General’s report went to your Senator and Congressman. The IG thinks we chiropractors are not to bright.
The latest IG report indicated they believe we should only see our patients on Medicare 12 visits each year…. And if you adjust your Medicare patient up to 24 visits, they believe you have committed fraud.
Because a large majority of Chiropractors have breached their contract with Medicare! We all signed a Federal Contract to KNOW AND FOLLOW the Medicare rules. Yet, the majority of Chiropractors do not know the rules and do not even know the correct way to DOCUMENT THE CHIROPRACTIC NECESSITY OF CARE BY Federal Standards.  If we don’t straighten up and do Medicare correctly we will lose the privilege of seeing Medicare patients because we will lose Chiropractic Coverage in Medicare!
Take a moment and evaluate your practice. There are 700 plus new Medicare recipients each day in America and that number is increasing. Chiropractors are not intentionally doing Medicare wrong. The simple fact, if you do not DOCUMENT THE CHIROPRACTIC NECESSITY OF CARE BY Federal Standards, that adjustment becomes now considered "maintenance care", a non-covered in Medicare. (AND S.O.A.P. Notes is not documentation!!)
 Either you or your chief Staff must learn to do Medicare correctly. We have shared our information with thousands over the past 33 years. The Chiropractors that have our information and used it correctly have lost NO audits. The reason being, our presentation shows the correct way chiropractors should be doing Medicare. 
If you have questions please give me a call. If you believe you are doing it correctly, give me a call before you receive a request for your records. 618-395-3800.
Best regards and protect chiropractic Medicare for the senior consumer freedom of choice and for chiropractic.

Friday, March 25, 2011

Chiropractic Medicare Patients with Other Payors

A Medicare patient is always a Medicare patient, even if they have another payor. When a Medicare patient has been in an auto accident for example, they are still a Medicare patient and all Medicare rules apply.
When billing another payer on this Medicare patient, remember to use the "AT" modifier after the Medicare covered services. This Medicare patient should be signing an ABN each visit as they should be aware Medicare probably will not pay for the covered services of the adjustments, and also non-covered services, like exams and x-rays.
The non-covered services, when billed, will be followed with the "GX" modifier and the Medicare covered services will have both the "AT" and "GA" modifiers, indicating active treatment but not paid by Medicare, so patient signed the ABN. Items #10A thru 10C on the claim form will indicate a PI case or WC case.
When the claim is completed, before mailing to PI insurance company, make two copies. One copy will be your office copy and the second copy will be sent to Medicare indicating to the Medicare Carrier of the PI case with this Medicare patient and telling the Medicare Carrier not to pay.
If you are a non-participating provider in Medicare you must remember not to bill any payer on this Medicare patient above the "limiting" charge Medicare has set for you. Mandatory Claim Submission says you must bill Medicare for covered services within one year of services.
If your patient for some reason loses the PI case, now Medicare should be notified and Medicare will pay to you 80% of the covered services that you have already billed. The only time Medicare should pay on a PI case is if the case has been lost. If Medicare pays on a PI or WC case to the doctor, when the case is settled the doctor must refund that in which Medicare paid, or the Medicare Carrier will take whatever was paid from the doctor's Social Security Retirement Fund.

Wednesday, March 16, 2011

Chiropractic Medicare - Modifiers AT GA GX

When billing for the Chiropractic adjustment and non-covered services,
modifiers are a must.  When billing 98940, 98941 and 98942, the "AT"
modifier is necessary to tell the Medicare carrier - this is "active
treatment" and to consider payment for this service.  This does not
mean they will automatically pay. If the doctor, after making an assessment of the patient each and
every visit, believes Medicare may not pay for this covered service
he may ask the patient to sign an ABN. All payable services 98940,
98941 or 98942 will be followed by "AT" and "GA" modifiers.
The lack of "AT" modifier after a payable service means the doctor is
asking the Medicare Carrier to consider this service as a nonpayable
service and telling the carrier NOT to pay. That is usually a mistake
because the adjustment to correct a subluxation is the only thing
Medicare reimburses.
The doctor also needs to learn to document so the
covered services in Medicare are reimbursed.
The "GX" modifier is only used when non-covered services are billed to
Medicare. This is done to receive a denial EOB for supplemental

Wednesday, March 9, 2011

Question: Do I have to bill Medicare for a Medicare patient with a Personal Injury Case?

A. FEES: All Medicare Carriers have posted the "NEW" fees for 2011. Go to your Medicare Carrier web page, click FEES. Go to 98940, 98941,98942 to find your fees in your specific local. Remember....the 98940, 98941, and 98942 WITHOUT the (#) sign are your fees in your office for your Medicare patients. The codes with the pound (#) sign are your fees if you adjust your Medicare patient in a facility other than your office.

B. Medicare PI, WC, or other payor than Medicare: When you have a Medicare patient with another payor than Medicare....remember, this is still a Medicare patient and you must follow Medicare Guidelines including billing to Medicare.

When you bill the PI insurance company for this Medicare Carrier, use all modifiers. Example: 98941 AT GA. The AT is active treatment and the GA tells Medicare carrier the patient signed the ABN because Medicare will not pay. Non-participating providers must also remember to NEVER bill the PI or WC insurance above your limiting fees. Participating providers may bill their regular PI fees on this Medicare patient.

Make a copy of the claim to the PI Insurance, one for your records and one you will mail to the Medicare Carrier. Item 10A thru 10C will indicate to the PI insurance that it is their responsibility and will also indicate to the Medicare Carrier NOT to pay this claim. It is billed to Medicare along with a bill to the PI...first because it is the federal law. Secondly, if the patient looses the PI case, now a copy of denial from the PI is sent to Medicare and now Medicare will pay.

NOTE: If you receive money from Medicare on a PI case.....and it is not paid back in a timely manner.....Medicare will take that amount out of your Social Security! This and much more is covered in our Chiropractic Medicare DVD and booklet.

Are Medicare Audits Triggered?

As long as we file a "clean" claim, most all Medicare carriers simply pay. However, there are a few things that "pop" out in a claim and lines us up for audits.

1. Item #14, Date of Current:
If date of current does not change in 60 days and the claim is with an "AT" modifier, an audit is probable. Date of Current #14 should change for any accidents, exacerbations, exams, x-rays, evaluations, etc.

2. Diagnosis must support care rendered:
The diagnosis for a patient with an exacerbation may be something like...Subluxation of L5, degenerative joint disease (if you have an x-ray less than one year) and sprain/strain, all in the same spinal region.

3. Patient Notes Review:
When asked to send one or two patient visit notes to your Medicare carrier and your patient notes only include S.O.A.P. notes and NO other "documentation" for the necessity of Chiropractic care, there is a problem. Now the Medicare carrier knows you do not know how to "document" and will do a full audit for money recovery.

Those are the three most prevalent reasons for an audit. Audits can be rough, however, if you know the correct way to do Chiropractic Medicare, after winning that first audit they will leave you alone.

The ABN Form

Your first impression about an ABN is "What a hassle!" However, an ABN is your friend. Both participating and non-participating providers have signed a contract with the federal government that you know and follow all Medicare guidelines.... including ABNs.

If the patient does not sign the ABN:
For participating providers, when receiving a denial EOB for a payable service, they can not get paid for that denied service from anyone including the patient. For the non-participating provider, who receives a denial EOB, will be instructed by the Medicare carrier to provide a refund to the patient if the patient paid at the time of visit.

ABN: Each patient visit, the doctor must see the patient prior to any services and make an assessment as to if the doctor believes Medicare will pay for all or part of the services that will happen today. If the doctor believes Medicare will reimburse for all services, the patient is not asked to sign the ABN.

However, if after the doctors assessment, after seeing this patient today, that Medicare may deny payment for all or part of the services that will be billed to Medicare, either the doctor or staff member will ask the patient to sign an ABN for today's services, give a copy of the completed signed ABN to the patient, and then provide the services.

The basic purpose of the ABN is to give the patient the choice that if Medicare will not pay for the service, the patient can either, sign the ABN and take financial responsibility, or leave the doctors office having NO services. The ABN, and all other important Chiropractic information, including documenting by Federal standards, are in the Chiropractic Medicare DVD.

Maintenance Care vs. Chiropractic Necessity of Care

Chiropractic Medicare was put together by Chiropractors in 1972-73. They did an excellent job of preserving the Chiropractic principles, even though the Medicare Carriers have done their best to twist it around so they can deal with us like other health care disciplines.

The only service payable for Chiropractic is the reimbursement for the correction of the vertebral subluxation. Not the "treatment" of pain or any other symptoms. For years, the Medicare Carriers have lead us down the "Yellow Brick Road" of treating patients symptoms, so when the symptoms are gone they want us to call the adjustment "maintenance care."

The consumer (our patient) gets cheated when the Chiropractor stops using the "AT" modifier because the patient's symptoms have decreased or are gone, even though they still are being adjusted for the payable service of correcting a vertebral subluxation because they still have subluxations.

The pressure is upon the Doctor of Chiropractic to learn the correct way to "document" the Chiropractic Necessity of Care if there is a vertebral subluxation. Not doing so, cheats the consumer, your patient, from Chiropractic reimbursement. Chiropractic maintenance is a patient that is checked, has NO subluxation, and is NOT adjusted.

When a patient is checked, has a subluxation and is adjusted, that is the primary job we Chiropractors perform and is a payable service in Medicare as long as the doctor "documents" the Chiropractic necessity of care. It is the Doctor of Chiropractic's responsibility to prove the subluxation, "document", and do it all correctly. If we Chiropractors do the job correctly Medicare is an excellent Chiropractic program.

Newsletters for February 2011

  • 02/08 Important Notes

  • 02/14 Our Medicare DVD

  • 02/22 A. Fees B. Medicare PI, WC, etc.

  • 02/28 P.A.R.T exam vs. X-ray
  • Newsletters for January 2011

  • 01/03 Chiropractic Medicare Notes

  • 01/10 Chiropractic Medicare
    Fees, Documentation & Florida Requests

  • 01/11 Chiropractic Medicare Fee Schedule

  • 01/17 The ABN (Advance Beneficiary Notice of Non-Coverage)

  • 01/31 What "Triggers" the Medicare Audit
  • Archived Newsletters for 2010

    We just recently started putting our newsletters on our website in 2010. For archived newsletters, please visit the link below.

    July Pre-payment Treatment Plan in Medicare
    June Fees in Medicare
    August CERT National Chiropractic Review
    September Documenting Chiropractic Necessity of Care
    September 27 Protect Yourself (What to send for a Medicare CERT Audit)
    October 4 Perfectly Clear
    October 13 A Better Understanding of the ABN
    October 18 Audit Wise
    October 28 CMS, Comparative Billing Report (CBR)
    November 1 Error Rate
    November 10 Medicare Audits and Your Response
    November 15 Veterans Chiropractic Bill and Medicare Executive Summary
    November 22 A Call For Action
    November 29 Participating Medicare Provider Window
    December 6 Everyday's a New Day!
    December 13 End of the Year
    December 20 Medicare Fee Cut One Year Extension Plus (RAD) "Requests for Additional Documentation Missing Percentages"
    December 27 Chiropractic Medicare Notes
    Ending 2010