Medicare Modifier Madness
Your office is a dream team of chiropractic all-stars and everyone needs to be at their best to provide high-quality service for your patients. As a member of the billing department, keeping your coding skills sharp is a must, but unfortunately, Medicare can make things especially tricky. Be sure that your claims contain the correct modifiers so that you have more slam dunks than fouls.
CMT Codes & Modifiers = A Winning Combo
Medicare only covers spinal adjustments when medical necessity thresholds are met according to their documentation requirements. Using modifiers when billing for spinal CMT informs Medicare the type of service provided (active vs maintenance treatment) and/or whether a signed Advance Beneficiary Notice (ABN) form is on file (if required).
Not sure how to distinguish between active and maintenance care? Click here to read more on this topic.
There are only 3 modifiers ever used on Medicare spinal adjustments: AT, GA, or GZ.
- AT: Used when you expect Medicare to pay for active treatment because the services are medically necessary and are reporting Chiropractic Manipulative Treatment (CMT) codes 98940, 98941, 98942 ONLY. An easy way to remember this is “AT= Active Treatment”.
- GA: Indicates the patient has been given advance notice that a service that is otherwise- covered, may not be covered today because the CMT service is deemed maintenance care or for some other approved reason. In this circumstance, the patient MUST sign an ABN form. If the patient chooses Option 1 on the ABN, you must bill the service to Medicare. An easy way to remember this is “GA= Got ABN?”
- GZ: Indicates that you expect an otherwise-covered service (98940-98942) to be denied as not reasonable and medically necessary, AND you failed to get an ABN signed prior to rendering the service. The claim will be denied automatically. GZ stands for “Geez, I forgot to have the patient sign the ABN form!”
The Starting Line-up of Modifiers for Statutorily Excluded Services
Then there are the services that Medicare never allows when ordered or delivered by a chiropractor: Evaluation and Management (E/M) services, X-rays, therapeutic modalities, active care procedures, orthotics, etc. You do not have to bill these services to Medicare unless the patient instructs you to do so. However, billing and collecting for these services from the patient is a must. The most commonly used modifiers for statutorily excluded services are:
- GY: Indicates when an item or service is statutorily excluded or was never covered when ordered or delivered by a chiropractor. This modifier applies to all codes except 98940, 98941, and 98942. GY stands for “Gee, WHY doesn’t Medicare cover this?”
- GP: Use this modifier with services delivered under an outpatient physical therapy (PT) plan of care. This refers to the service being a physical therapy CPT code, not necessarily that it was performed or ordered by a physical therapist. An easy way to remember this modifier is “GP= Got PT?” It may be used with the GY, GX, and/or the X series of modifiers for separately identifiable services.
- GX: Used to report when a voluntary ABN, using Medicare’s official form, is issued for services never covered when ordered or delivered by a chiropractor. Use this modifier only if you chose to notify a Medicare patient of statutorily excluded services using the official Medicare ABN form (not recommended).
Get an Assist from Modifier 25 and 59 (or XE, XS, XP, or XU)
Although modifier -25 and -59 are not exclusive to Medicare, sometimes they are needed to get the claim processed correctly. NOTE: Medicare has specific rules about modifier 59 that may require use of one of the X codes above. Use the 25 modifier when an E/M service is performed on the same day as a CMT. The 59 modifier is used mostly with rehab/physical therapy codes to show that the services provided were separate and distinct from one another. You may also use one or more of the other modifiers previously discussed in conjunction with modifier 25 or 59.
There’s more to the -25 modifier then you think! Click here to read our blog on the Do’s and Don’ts of Modifier 25.
Keeping Score: Perform Coding Audits for Better Compliance and Proper Reimbursement
ow that you know what modifiers team up with the CMT codes you use in your office, it’s time to run some practice drills and make sure they are being used properly. Is the AT modifier only being used for Medicare patients under active treatment? Do you have a signed ABN form on file for patients that have a GA modifier attached to their CMT code? Do you have all the modifiers you need for statutorily excluded services?
Proper coding matters. Although Medicare only pays for spinal manipulation for active treatment, a patient may have a secondary insurance that will pay for excluded services. Improperly coded services will result in claim denials that ultimately can have a negative impact on your collections. Avoid the bench by using the correct modifiers! Become a chiropractic coding MVP and help your office score big!
Dr. Karen Sedore has over 10 years of experience working in the chiropractic profession. She began as a manager specializing in billing and medical necessity as well as taking on chiropractic assistant responsibilities so that she could be more involved with patient care. In 2016, Dr. Sedore received her doctorate in Chiropractic from National University of Health Sciences. She joined KMC University in 2017 and assists doctors and their staff in her current role as an Membership Advisor.