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Don't miss the April 2023 edition!

We know you count on us to keep you up to date with the most important information in the profession. We have compiled updates, blogs, and news for you into this convenient digital publication.

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Medicare Billing Rules

Medicare Billing Rules

Once you have an understanding of the different types of Medicare plans, and are ready to submit claims to the appropriate plan, it is important that your billing be accurate. Most Medicare denials are preventable if you follow the billing rules. Unfortunately, many providers are completely unaware of the rules and therefore make costly mistakes. Invest in your practice by getting to know the basic rules of Medicare billing.

Paper or Electronic- Do You Have A Choice?

The Administrative Simplification Compliance Act (ASCA) prohibits payment of initial health care claims not sent electronically, except in limited situations. The exclusion that applies to most Doctor of Chiropractic is the ‘small provider claims.’ CMS states:

Physicians and suppliers with fewer than 10 FTEs and that are required to bill a Medicare Administrative Contractor (MAC) or Durable Medical Equipment (DME) are classified as small. See section 90.1 of Chapter 24 of the Medicare Claims Processing Manual (Pub. 100-04) for more detailed information on calculation of FTE employees and this ASCA requirement in general, and/or claims from providers that submit fewer than 10 claims per month on average during a calendar year.


Don’t assume you qualify for paper submission. Be sure to consult the details in the Medicare Claims Processing Manual. For example, did you know, workforce members who perform services for a provider under contract, such as individuals employed by a billing agency or medical placement service, for whom a provider does not withhold taxes, are not considered members of a provider’s staff for FTE calculation purposes? Don’t count these individuals!

How about part-time workers – did you know, part time employee hours must also be counted when determining the number of FTEs employed by a provider. For example, if a provider has a policy that anyone who works at least 35 hours per week on average qualifies for fulltime benefits, and has 5 full-time employees and 7 part-time employees, each of whom works 25 hours a week, that provider would have 10 FTEs (5+[7 x 25= 175 divided by 35= 5])

OOPS! A Post-Payment Enforcement-What Should You Do?


Incorrect Claim Submission

According to CMS the process is as follows: “Your Medicare contractor will analyze reports displaying the number of paper claims that all providers submitted each quarter. By the end of the month following the quarter, selected providers who have submitted the highest numbers of paper claims will be reviewed. Medicare contractors will ask these providers to provide information that establishes the exception criteria listed above. If you, as one such provider, do not respond to this initial “Request for Documentation” letter within 45 days of receipt, your contractor will notify you by mail that Medicare will deny and not pay any paper claims that you submit beginning ninety days after the date of the initial request letter. If you do respond to this initial letter, and your response does not establish eligibility to submit paper claims, the contractor will notify you by mail of your ineligibility to submit paper claims. This Medicare decision is not subject to appeal.”

When in doubt reach out to your local Medicare Administrative Contractor (MAC), they often have helpful tools online to assist with determining eligibility for paper claim submission. Do not ignore post-payment request. Train your staff to keep an eye out for them.

So, what about those modifiers? Check out Know Before You Bill-Medicare Modifiers


More On Medicare


The Four Parts of Medicare


Medicare Modifiers


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When you become a client of KMC University, you have a wealth of information at your fingertips. You have access to training webinars, a multitude of document templates for Medicare, coding and documentation, and a complete Patient Financial System.

Maria Elena Wilson, Tri-Lakes Chiropractic