Chiropractic Medicare Diagnosis (newsletter from 4/11/11)

April 11, 2011

Chiropractic Medicare Diagnosis

There are two factors involving the diagnosis of great importance. The diagnosis must be an honest diagnosis and that diagnosis must support the care rendered.

The first part of our Chiropractic diagnosis will always be a vertebral subluxation. It is our privilege and responsibility to determine the primary subluxation. Item 21, section #1 on the CMS-1500 form, will begin with the primary subluxation, either 739.1, 739.2, 739.3, 739.4 or 739.5.

After determining the primary subluxation, now you must determine the second part of the primary diagnosis. Since we are speaking about seniors over the age of 65, after doing x-rays (x-rays are mandatory each 12 months if the Chiropractor "proves" the subluxation by x-ray) the second diagnosis, since the subluxation has been present for the past 30 years, is degenerative joint disease. (You can see this condition on x-rays less than 12 months old.) This diagnosis goes in Item 21 section #2.

The third part of the diagnosis is usually why the patient came to your office. An exacerbation is any event, great or small, that has insulted pre-disposed soft tissue creating pain that the patient can place and exact time and date. Soft tissue in a predisposed degenerative joint has been insulted, stretched, torn, twisted and may be bleeding called sprain/strain.  That is the third part of the diagnosis entered into item 21 section #3.

The fourth part of item 21 will probably be your next important subluxation.

NOTE:  Each time there is a new exacerbation, date of current, item #14 is updated to date of exacerbation.     

Understanding Medicare Fees as a Chiropractor

(for Providers that are Participating or Non-Participating, Accepting Assignment or Not)
I know you are very busy.... but please read and understand the importance of this message! It may save you "big bucks"!
We do have a dual fee schedule in our Chiropractic offices. They are our normal customary fees and the fees set for you in your state local by your Medicare Carriers. DO NOT MIX THEM UP!

As a participating provider, even though your Medicare Carrier has a set fee for you, you may bill your Medicare Carrier for a payable service (98940, 98941 and 98942) whatever fee you wish. Your Medicare Carrier has the responsibility to reimburse back to you 80% of the Medicare fee only. Not the amount you billed. You must collect from the patient the other 20%, either from the patient or supplemental insurance, not one penny above the Medicare fee set by your Medicare Carrier.

As a non-participating provider, marking the box you accept assignment (money sent to the doctor), you can NOT bill the Medicare Carrier above the non-par fee set for you by your Medicare Carrier. You also must collect the 20% from your patient or supplemental insurance. You can never receive payment from Medicare or your patient above the non-par fees set for you by your Medicare Carrier.

As a non-participating provider, NOT accepting assignment (running business like it should be run.....patient comes in, gets a great Chiropractic adjustment, goes to the front desk and pays for everything), you can collect from your patient, at time of visit, for the adjustment the "limiting charge" (113% higher than participating provider fees). You bill Medicare the "limiting charge" and the Medicare Carrier pays, to your patient, 80% of the non-par fee and their supplemental insurance pays 20% to your patient.

If either participating or non-participating providers collects money from anyone above the set fees of your Medicare Carrier, the fines begin at $10,000.00 per incident. If a non-participating provider bills the Medicare Carrier or any payer (PI, WC) on a Medicare patient above the limiting fees set by your Medicare Carrier on a Medicare patient, the fines begin at $10,000.00 per incident.