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Tuesday, August 28, 2012

"The Medicare Claim Tells the Story" ~Newsletter 8/20/12

August 20, 2012
Chiropractic Medicare
"The Medicare Claim Tells the Story"

 Most of my fellow Chiropractors, when they call about an audit or pre-pay request for records, ask why they received the record request.  Most of the time they have a request for records because the items on the claim do not match.

 An example:  A claim with an acute diagnosis indicating an acute condition or an exacerbation may have in item #14, Date of Current, a date over 60 days.  This tells the carrier the condition is chronic so the doctor receives a request for records to verify the true story on the patient. 

Date of Current on an active patient should NEVER be over 60 days if your are expecting Medicare reimbursement.

 Or...the diagnosis only consists of a subluxation with maybe arthritis.  The carrier knows this patient can be adjusted twice a day for 6 months and an x-ray indicated a subluxation and arthritis.  No improvement and no reimbursement.  The diagnosis should have three parts to it.  An example: subluxation, arthritis and sprain/strain if there has been an exacerbation.

 If item #19 does not have both date of x-ray(less than one year) or P.A.R.T., the claim may not be payable.  The carrier may ask for patient records to verify if the doctor proved a subluxation by either an x-ray less than one year or a P.A.R.T. form for each visit.  X-rays are mandated each year, if the doctor proves subluxation by way of x-ray. A P.A.R.T. form is mandated each visit if the doctor does not use x-rays to prove the subluxation.

Some carriers ask for office patient records periodically to verify if the doctor has a treatment plan with the three key components.  The "documentation" provided by our program consists of both "Federal Documentation" and also a treatment plan meeting all three components.

Many times the carrier will ask for patient S.O.A.P. notes to verify the doctor did in fact adjust vertebrae is specific regions in which they billed Medicare. If you adjust 4 regions on your patient for example, your billing will match the S.O.A.P. notes as to the number of regions you adjusted and billed to Medicare.

 Generally the information on each claim should all match.....diagnosis supports the care rendered, Item #14, date of current, is less than 60 days old, Item #19 contains date of x-ray or P.A.R.T., and specific terminology indicating any exacerbation and the "documentation" has been produced.

 Once the correct way to do Medicare is understood, you are half the way. 

"ABN - Important!" ~Newsletter 8/14/12

August 14, 2012
Chiropractic Medicare
"ABN - Important!"

If a patient selects Option #2 on the ABN, the service indicated on the ABN does not then become a non-covered service.  However, the doctor does not have to file a claim to Medicare in that particular instance because the patient indicated that he or she agrees to pay out-of-pocket and does not want a claim submitted to Medicare. (However, the patient can change his or her mind, at a future time, and request the provider to submit a claim to Medicare.)  Both participating and non-participating providers are permitted to ask for payment from the patient at the time of service if either Option 1 or Option 2 is selected on the ABN.

It is my opinion that the purpose of the ABN, a rule that supersedes the Mandatory Claims Submission Law, is a simple attempt to supply a process to not bill Medicare for our seniors so the carrier's do not have to reimburse for Chiropractic adjustments.  That is a deceiving way to cheat our seniors from reimbursement in Medicare in which they have already paid, plus they pay a Medicare premium each month for coverage.  I strongly recommend we Chiropractors provide great Chiropractic care to the seniors, learn the correct way to do Medicare and bill Medicare so our seniors get their due reimbursement.

Remember...the ABN should only be presented to patients when the service in question may be denied by Medicare due to medical necessity.  It is not appropriate for the provider to present a patient with an ABN for a service that is expected to be covered.

The Chiropractic adjustment is ALWAYS a covered service by Federal Law and it is the responsibility of the Chiropractor to learn and provide "documentation" so the covered service is payable.

Newsletter 8/06/12 ~ "Back to the Basics"

August 6, 2012
Chiropractic Medicare
"Back to the Basics"

The simple fact is "if you do not know how to do Chiropractic Medicare correctly...there is trouble!"  So most important....learn the correct way to do Chiropractic Medicare.

We have had the privilege of sharing, with our fellow Chiropractors and their staff, Chiropractic Medicare information for the past 34 years.  We constantly hear remarks like, "I have been in practice for 27 years.  Why didn't someone tell me this before now?" 

 You may believe you are doing Chiropractic Medicare correctly.  However, question yourself.  If you receive an audit today in the mail, what does your documentation look like? (Documentation is not S.O.A.P. notes.)  What does your treatment plan look like and does it have all three (3) required elements?

Questions? Please call me!  800-MY-CHIRO

"Audit....Notes of Interest" ~Newsletter 7/31/12


July 31, 2012
Chiropractic Medicare
"Audit....Notes of Interest"

"Documentation" requirements for Chiropractic Care following the initial visit, these include:

1.       History:  Review of chief complaint.

a.       Changes since last visit.

b.      System review - if relevant.

2.       Physical Exam:

a.       Examination of area of spine involved in diagnosis.

b.      Assessment of change in patient condition since last visit.

c.       Evaluation of treatment effectiveness.

3.       Documentation of treatment given on day of visit.


NOTE:    Documentation cannot be used to substantiate medical necessity retrospectively.  In other words, documentation for medical necessity of care must be produced at time of visit.  Medicare guidelines require that medical need be established prior to providing the service at issue.  The medical record must stand on its own with original records supporting that the billed services is medically necessary and reasonable.


Those of you using our information, be sure to complete the "documentation" at time of visit.  If audited, include, with your documentation, the additional requirements listed at the first of this article.