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No Surprises

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Your summary of the latest reimbursement and compliance news.

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Your medicare questions answered

Q: Is it best to sign an Advanced Beneficiary Notice (ABN) every year?

A: ABN forms are not calendar year specific. Once an ABN form is signed, it is valid for 12 months. If during that 12 month period, the patient reactivates into an episode of active treatment (CMT-AT), this ABN is then end-dated. At the end of that active episode, upon the first visit of the new period of maintenance, a new ABN is signed which will be good for up to one year under the same circumstances.

Q: How do I find out about Medicaid coverage for chiropractic services in my state?

A: A great place to start is to search in your web browser for the Department of Human Services [your state] or the term Medicaid [your state]. The other option is to type Mecicaid.gov in your browser. These options should lead you to your state department for Medicaid services where you can locate coverage exclusions, provider enrollment forms, and specific benefits.

Q: I keep seeing the remark code CO (Contractual Obligation) on Medicare Electronic Remittance Advice (ERA)/Explanation of Benefit (EOBs) for therapy services. I am adding the GY modifier; am I missing something?

A: There was a rule for Medicare that was not strictly enforced until January 2018. The use of modifier GP indicates that a service was performed as part of an outpatient physical therapy plan of care. In addition to the GP modifier, you would also include the GY modifier when billing Medicare for this statutorily non-covered service. The use of the GP modifier applies to all 97XXX and G0283 codes that are billed to Medicare. (Hint: United Healthcare and some other payers are also asking for this GP modifier)

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: A Provider Transaction Number (PTAN) is the number that an entity (individual provider or clinic/group) receives once approved for enrollment with Medicare. This number is only for use within Medicare and will be used as an identification factor when calling into Medicare. The fact that you have an assigned number ensures Medicare that you have completed their enrollment process. A Chiropractic entity must maintain an active PTAN to continue to treat Medicare patients. If you do not revalidate or do not submit a claim within 1 year, your PTAN will become deactivated.

Q: How do I bill Medicare for statutorily excluded services such as exams, therapies, and x-rays?

A: When submitting Medicare claims for statutorily excluded services, each service must have a “GY” modifier. For therapy services, you must include the “GP” modifier (GY GP). The GP modifier is also referred to as the “Always Therapy” modifier. When sending E/M services to Medicare for secondary consideration you may want to include the “25” modifier if the E/M service is separate and distinct from the CMT service. E/M services must always have the GY modifier signifying that you realize this is a statutorily excluded service (25 GY). Keep in mind that you are NOT REQUIRED to bill Medicare for statutorily excluded services, however, if the patient has secondary insurance, billing these services to Medicare will ensure that they are denied appropriately in order for the secondary to respond.

Q: What is the Qualified Medicare Beneficiary (QMB) Program?

A: The QMB program is a Medicaid benefit that assists low-income Medicare beneficiaries with Medicare Part A and Part B premiums and cost sharing. It includes deductibles, coinsurance, and copayments. In 2016, 7.5 million individuals enrolled in the QMB program. Of that total, about twenty-two percent received Medicaid coverage of their Medicare expenses only (QMB Only), and seventy-eight percent received full Medicaid benefits in addition to coverage of their Medicare expenses (QMB Plus).

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 into 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 after the ABN is signed by the patient which informs the patient that you have reason to believe it won’t be reimbursed.

Q: What can you do when you are treating two regions of the spine in an active care program, but are also delivering maintenance care to other regions?

A: According to Medicare guidelines you can only bill Medicare for what is medically necessary. That means you can’t charge separately for maintenance care. You should document the care and only bill Medicare for the appropriate levels. This is not considered “gifting” as you are just adhering to Medicare guidelines.

Q: I am making an unexpected trip out of town—I’ll be gone for a week. I have a substitute doctor covering the practice; what billing procedures should be used to ensure we are staying compliant?

A: The answer depends on several factors; the most important is whether or not you have a written agreement with the substitute doctor and how the doctor is being paid. Normally, a substitute doctor covering for another doctor for a vacation will make a reciprocal billing arrangement (e.g., two physicians exchange coverage for vacations). This is an informal arrangement and does not require a written agreement. The regular physician’s 1500 claim form (with NPI in box 24J) will need to be appended with the Q5 modifier. If the time away will be extensive, the regular physician should make a fee-for-time compensation arrangement (previously known as locum tenens) with the substitute doctor. The payment is NOT an exchange of services but rather a fixed per diem amount. According to Medicare, the substitute doctor does not need to be registered with Medicare to perform the duties of the Locum Tenens (although some commercial carriers (e.g., Medicare Advantage plans) may have different rules. When billing for these services, your NPI still goes in 24J and the Q6 modifier is appended. The office needs documentation reflecting the dates that the locum tenens provider was covering and those patients that were treated under his/her care.

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 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 in conjunction with a Functional Outcomes Assessment in order to indicate a Functional Deficit.
3) Documentation of the Initial and Subsequent Visits. Specific documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination. Medical Necessity must be documented for each region that is adjusted along with re-evaluations to document the effectiveness of the treatment plan.

Q: Someone told me that I cannot collect for hot/cold packs (97010) from my Medicare patients. I know I cannot give away free services to these patients. What do I do?

A: Medicare considers CPT Code 97010 (hot/cold packs) a ‘bundled’ service. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. In this instance, it means services described by 97010 are not separately billable when rendered to a Medicare patient. It is considered a part of whatever primary service is rendered to the patient, and in the case of chiropractic that will be a CMT code (98940-98942). This is different than a ‘non-covered’ service, which can be charged to the patient. A bundled service cannot be charged to the patient, as it is being reimbursed within another code’s value.

Q: My client signed up for ChiroHealthUSA. Can I apply the ChiroHealthUSA fees and then submit the services to Medicare so that they cross over to the secondary for payment?

A: Unfortunately, no, it doesn’t work that way. Patients can either use their insurance OR they can use ChiroHealthUSA for the services. This applies to offices that offer a Time of Service Discount, as well. It is one or the other—not both.

Q: Since Medicare doesn’t pay for statutorily excluded services, do I have to charge the patient?

A: In order to avoid federal penalties, you must charge every patient for every service rendered. Otherwise, you are vulnerable to Inducement Violation which can generate an avalanche of violations that start when you offer federally funded patients services that are free or outside the 5-15% time of service guideline (as set forth by the OIG). The safest way to offer a greater discount is by using a discount medical plan such as ChiroHealthUSA or properly verifying the patient’s financial need according to your written hardship policies.

Q: I have a question regarding Medicare dx codes. We are billing a set of dx codes and they are coming back denied as not medically necessary. I used S13.4XXD with the subluxation code.

A: It is extremely important to be familiar with the Local Coverage Determination (LCD) for chiropractic services issued by your Medicare Administrative Contractor (MAC). You will find that some jurisdictions release a list of covered secondary diagnoses. In many of the LCDs, S13.4XXA is a recognized diagnosis. You used S13.4XXD which indicates to Medicare that the services rendered were more maintenance or preventative. In this scenario, this patient appears to be experiencing a new onset of an “old” injury. Since this is a new onset, you should conduct an examination, document it appropriately, and consider using an “A” for the 7th character. The 7th character “A” is used to report a patient who is currently having complaints that should be treated in an active or corrective manner.

Q: What is a Medicare Advantage Plan?

A: According to www.Medicare.gov, a Medicare Advantage Plan (like an HMO or PPO) is a Medicare health plan that qualified beneficiaries may choose as part of their Medicare packages. These plans are very similar to traditional Health Management Organizations (HMOs), Preferred Provider Organizations (PPOs) and Private Fees for Service (PFFS) plans. They technically replace traditional Medicare Part B in the sense that the carrier handles all benefits and claim processing.

Q: Can Medicare providers seek payment for Medicare cost-sharing on QMBs from State Medicaid Programs?

A: Yes, as permitted by federal law. Most States limit their payment of Medicare deductibles, coinsurance and copays. In most cases, the provider must complete a State Provider Registration/Enrollment process and be entered into the payment system in order to bill for cost-sharing services.

Q: Can I use the ABN form as a work-around to enrolling with Medicare?

A: The ABN is not a work-around for enrolling with Medicare. In the chiropractic setting, the ABN is only used when the provider is actively enrolled as either a Participating or Non-Participating provider.
It is not appropriate to use the ABN form if the provider is not actively enrolled with Medicare. An ABN does not protect the provider from the mandatory enrollment requirement.

Q: Does Medicaid pay Medicare premiums and deductibles?

A: In some instances, Medicaid pays the deductibles, coinsurance, and premiums for Medicare Part A and B for low-income individuals. These cases are referred to as “Qualified Medicare Beneficiaries” or QMB’s.

Q: In order to verify QMB status I heard we should use HETS. What is HETS ?

A: The HIPAA Eligibility Transaction System (HETS) is intended to allow the release of eligibility data to Medicare providers for the purpose of preparing an accurate Medicare claim, determining beneficiary liability, or determining eligibility for specific services. The submitter needs to complete a Trading Partner Agreement (TPA). Refer to the HETS Help ‘How to Get Connected’ page download section for a copy of the form: https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/HowtoGetConnectedHETS270271.html. You would utilize this same resource for ANY QMB status.

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After watching the webinar “Security Risk Management, A HIPAA Requirement”, I went to the government website and spent 4 hours trying to research what I needed to do and had to walk away as I was overwhelmed.  After contacting my Account Manager, and setting a time to review the Compliance materials that are available at KMC University, I now feel this is what I was looking for…simple steps to walk from A-Z.

Amy D.
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