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Chiropractic Medicare FAQ

Medicare FAQ

Q: Is it best to sign an ABN every year?

A: The ABN is valid for 12 months unless you deliver a covered CMT (chiropractic manipulative therapy) service in that time period. Once you bill for a covered CMT, your ABN is invalid and a new one will be required when you go to non-covered CMT again.

Q: We are thinking about hiring a new doc. If he stays cash but wants to adjust Medicare patients, does he still have to go non-par? He is thinking he can still treat Medicare patients by just having them sign an ABN.

A: All providers who treat Medicare patients are required to be registered in the Medicare system. If you're not a registered provider, use of an ABN is not a protection for you and thus you cannot collect from the patient, nor would you be able to collect from Medicare. Seeing Medicare patients for free is an inducement violation, so, as you can see, there really isn't a good option there. There has been some discussion about the patient’s right to elect to not disclose their information regarding their Medicare enrollment, but the providers are supposed to ask first, then the patient has to insist and request a way to use that restriction  It can’t be doctor-suggested or led, which means it can’t be a policy or a requirement in your office.  

Medicare has a mandatory claims submission rule, so you need the ABN to avoid that for maintenance - but as a non-registered provider you aren’t allowed to use the ABN.  His best option is to be non-par with Medicare, charge his limiting charge to Medicare beneficiaries and submit claims so they can be repaid. If he doesn’t want to do that, he will have to refer any Medicare patient that comes in to the closest registered Medicare provider.  

Q: Our patient has health insurance with CHP and Medicare part A (not part B). Do we have him sign the ABN? And what should I charge him for his adjustment? 23.90 or his $20 copay w/ CHP?

A: If you’re certain that this patient has no Part B, then there's no requirement for using an ABN for Medicare, since he has no physician coverage. In fact, the ABN gives you no protection when it is used improperly. Please verify with your Medicare carrier that the patient does not have Part B coverage. When you are certain he does not have Part B, then CHP will be the only coverage available and you should follow the rules and coverage limitations for that plan. CHP will have specific rules for coverage so be sure you know those rules and how they pertain to chiropractic care.  

Q: Can Medicare patients opt out of filing and pay a discounted cash rate?

A: Chiropractors may not "opt out" of Medicare like MDs and DOs can do. Medicare patients can request under the new HIPAA rule that you not disclose and information to any carrier - including Medicare. But careful. The law says you may not lead the patient in this decision and you may not make it a condition for treatment in your office.  Here’s what can happen: Mrs. Jones comes into your office and says, “I’m so suspicious of the government getting involved in my healthcare, is there any way I can just pay you cash and you just hold those bills to Medicare?” As a registered provider with Medicare you can say, "There's one way we can do this, Mrs. Jones. I have a form you can complete that will block me from releasing any information to any carrier. That doesn’t mean you can bypass Medicare to some other carrier, it means NO carriers will get your information. Is that what you want?”  It has to be entirely patient-led and patient-requested. You can remove yourself from Medicare but you would be required by federal rule to refer your patients to a registered Medicare provider.

Q: How can we effectively explain to Medicare patients that exams and re-exams are a requirement under Medicare rules even though they’re not a covered service?

A: We really like to use the Patient Media Medicare brochures and the Medicare Worksheet. Both offer succinct, easy-to-understand language for patients.

Q: Can you clarify the new Medicare X modifiers?

A: The new X modifiers supplement, rather than replace, modifier -59 for Medicare. At this time, only Anthem Blue Cross and United Healthcare have stated they will include the X series modifiers. As the only service required to be billed to Medicare is CMT, those modifiers will not be required for our CMT claims. Keep in mind that the -59 modifier isn't going away, but these X series modifiers are being added for more clarification and are only to be used when the -59 is not clear enough. There has not been enough information to clearly define when to use these modifiers as of yet and we are monitoring the situation closely to stay on top of updates.

Q: I am a par provider with Medicare. If I set my 98940 and 98941 fee to be the same is that ok? I realize that it won’t change anything except on the self-pay side.

A: You certainly can set all of your fees the same for each of the CMT codes.The idea is to make sure that your fees are set according to relative value units (RVUs) and other factors while making sure that no dual fee scenarios are in play. If you charge, for example, $40 for 98940, 98941, and 98942, nothing stops you from doing so. Just make sure that this “actual” fee is the same charged to everyone. 

Q: I have a patient who I have been treating off and on for a few years. Recently he was hit (punched) by one of the caregivers who had been taking care of his significant other. My patient has Medicare. Should I bill Medicare? What do I do from there? Do I bill from my regular fee schedule?

A: You have a complicated situation here. If he was punched by a caregiver, is there intention of suing the caregiver or the company? Context of the blow aside, you're correct to question whether Medicare would be primary. The moment the notes say this was because of a third-party action, Medicare will immediately become secondary. If there is nobody else to sue or to expect payment from, then you would bill Medicare as per usual, with a new condition date in Box 14 of the 1500 billing form, and start a new episode of care relative to this incident. There should be no problem calling this acute treatment.

If there is intention to sue or bring a third-party action, you will want to review all the rules of Medicare as a secondary payer

Q: What is a PTAN number? I am trying to get information from Medicare and they say they need this number first. Do we have one? I have an NPI, why won’t that work?

A: In order for a provider to enroll in Medicare, the provider must have a National Provider Identifier issued by the National Plan and Provider Enumeration System (NPPES). The NPI is used to identify providers in the HIPAA standard process, such as the claims submission process. Once the NPI is issued, the provider can complete a CMS 855 provider enrollment application and send it to Medicare Administrative Contractor’s (MAC) Provider Enrollment Department.

The MAC’s Provider Enrollment department issues Medicare Providers a Medicare Transactions Number called the Provider Transaction Access Number (PTAN). The PTAN is used for claims processing system and access to information purposes. A Medicare Provider is issued PTAN for each entity a provider works for. The PTAN identifies who rendered services to a Medicare Beneficiary in the Medicare claims processing system. A provider will need the PTAN to access data on the Interactive Voice Response (IVR) phone system. A group claim will also receive a PTAN and can be used for identification purposes when contacting Medicare.

When you were enrolled in Medicare, they sent a letter that showed completed enrollment and it also listed your PTAN number. If you need a new letter sent to the provider to obtain this number, you can call Medicare and request that it be resent.

Q: I’m a little frustrated. Medicare requires x-ray for documentation but does not pay on x-ray. How can they require something and not pay for it?

A: According to Medicare:

“An x-ray is not required to demonstrate subluxation. An x-ray may, however, be used for this purpose if the chiropractor so chooses. If the chiropractor chooses to use an x-ray to demonstrate the subluxation, then the documenting x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment.

Unless Medicare concludes that more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment.”

Q: What can I give away or discount to my Medicare patients?

A: Coupons, exam specials, or other similar discounts should not exceed $15 individually or $75 annually per patient. Most likely, your exam is not going to fall into this $10 range, and if it does, we have a lot more to work on! The OIG has lots of information on this.

Q: Medicare is denying my claims, and the remark code is saying level of service not justified. Help!

A: Medicare only pays for chiropractic adjustments. Because of this, the level of service they're referring to is your adjustment codes (98940, 98941, 98942). Check to see if your objective findings match your level of service billed. For example: if you bill a 98942 but your objective findings only show two regions, Medicare will down-code and more likely simply deny the claim for lack of medical necessity.

Q: When billing Medicare, is there any other modifier we can use besides the AT modifier for an adjustment code in order to receive payment for other line items?

A: You’d use the GA if you had an ABN form signed. Remove the AT modifier if you're not providing active care, and the care is maintenance. The combination of the lack of an AT modifier and the addition of the GA modifier signifies maintenance care. Use GY and/or GP when also billing any other service, if you want to receive a denial so you can bill a secondary.

Q: If a patient goes over the 30 visits for Medicare, do we continue to bill Medicare or transition them to time of service?

A: According to Medicare, they don’t have a “cap," they have a “screen.” If a patient’s care is still truly medically necessary, you can continue to send it in to Medicare with an AT modifier. Having said that, if you have reason to believe the care won’t be reimbursed by Medicare, you can add the GA modifier as well, after having the ABN signed by the patient to inform the patient that you have reason to believe it won’t be reimbursed. If they do ultimately reimburse you for the care, the patient will only owe their 20% co-insurance - but if Medicare doesn’t pay, you are able to collect from the patient.

Q: We are currently a non par provider with Medicare. What is the rule about charging patients when an active treatment manipulation has been denied as medically non necessary? Do we as the provider have to eat that charge or can we bill the patient?

A: Since you are a non-participating provider with Medicare, the patient would have already paid for that visit at the time of service. Because Medicare is telling you that the visit is seen as “not-medically necessary,” you must refund the patient what they paid you for the CMT code only. If you also collected for other statutorily non-covered services, these do not have to be refunded. As a non-participating provider, you don’t have the right to appeal unless the patient assigns that right to you. But if your Medicare bills are being denied, it screams of a much bigger problem. Are you using proper modifiers? Do you understand the difference between acute, chronic, and maintenance visits? Do you know the decision-making process that is required on a visit-by-visit basis on these kinds of patients? If not, let us help you! 

Q: I’ve heard the term “ABN Modifiers” several times - what are they?

A: The Advance Beneficiary Notice (ABN) is a notice given to beneficiaries to convey that Medicare is not likely to provide coverage in a specific case. Providers must complete the ABN and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice. (from The following modifiers are used to communicate the status of the ABN concerning a specific patient:

GA – Waiver of liability statement issued, as required by payer policy

GX – Notice of liability issued, voluntary under payer policy

GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit

GZ – Item or service expected to be denied as not reasonable and necessary (forgot to issue ABN to patient)

Q: I keep getting Medicare claims that are denied with remark code MA130. How do I appeal?

A: Claims rejected as unprocessable (remark code MA130) do not have any appeal rights, but instead must be resubmitted as new claims. For example, if a claim you submitted contains a small clerical error or omission (e.g., transposed numbers, mathematical mistakes, computer errors, etc.), this may be corrected through the reopening process, but not through the appeals process.

Q: We received a Medicare EOB with the code 223 and they are taking .39 cents off of 98940 and .53 cents off of a 98941. What does this code represent?

A: The code 223 is new due to the “sequestration reduction” based on the federal budget. The amount of reduction is applied to the allowable fee and therefore is an additional write-off, which you cannot collect from the patient. We hope it is temporary, however, as there has of yet been no approved budget out of our federal government, this is still being applied.

Q: What does Medicare need in my documentation in order to establish medical necessity?

A: Medicare’s utilization guidelines for chiropractic services require the following three components in order to establish medical necessity:

  1. Presence of a subluxation that causes a significant neuromusculoskeletal condition. Medicare will not pay for treatment unless it is by manual manipulation of the spine to correct a subluxation. The subluxation must be consistent with the complaint/condition.
  2. Documentation of the Subluxation. A subluxation may be demonstrated by one of two methods: x-ray or physical examination. If documented by physical examination, the PART system must be used.
  3. Documentation of the Initial and Subsequent Visits. Specific documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination.