The Medicare Hurdle That Continues to Block
Our Professional Progress
Dynamic Chiropractic ~ April 9, 2012
The rules for Medicare are spelled out in section 240 of chapter 15 of the Medicare Benefit Policy Manual  and in your local carrier's or administrator's Local Coverage Determination (LCD). The terminology is generally consistent; however, it can be confusing based on how the language is misinterpreted by chiropractors and those who teach documentation and coding seminars. Contrary to what many believe, Medicare documentation is not subluxation-based, even though parts of section 240 can mislead one in this direction. Why do we say this? Because "subluxation-based" to chiropractors is a different concept compared to subluxation-based to Medicare, and this fact is clearly spelled out in the rules.
Patients in Medicare Demonstration Project
Give Their Chiropractors High Marks
ACA News ~ January 26, 2010
According to long-awaited results from a congressionally mandated pilot project testing the feasibility of expanding chiropractic services in the Medicare program, patients have a high rate of satisfaction with the care they receive from doctors of chiropractic. When asked to rate their satisfaction on a 10-point scale, 87 percent of patients in the study gave their doctor of chiropractic a level of 8 or higher. What’s more, 56 percent of those patients rated their chiropractor with a perfect 10.
Correctly Completing a Medicare Claim
This article takes a step-by-step analysis on what goes in each box on the HCFA form, and reviews the proper use of modifiers.
American Chiropractic Association Responds to the May 2009 OIG Report
In a response released today, the American Chiropractic Association (ACA) refuted the findings and recommendations outlined in a May 2009 report released by the Department of Health and Human Services Office of the Inspector General (OIG), noting the methods used by the OIG may have resulted in an overestimate of inappropriate claims. In commenting on the report, ACA said the OIG’s decision to restrict data collection to only those episodes of chiropractic care resulting in claims of more than 12 visits by the same doctor, likely skewed the data pool by focusing on a subpopulation previously identified to be more problematic. As a point of comparison, an OIG report released in 2005 investigated data collected from a global sample of claims. You may review OIG's 2009 Full Report or the 2005 Full Report immediately.
Medicare Documentation Guidelines
The American Chiropractic Association
The American Chiropractic Association provides this commentary in order to assist its members to better understand the Medicare PART clinical documentation guidelines. These are Centers for Medicare and Medicaid Services (CMS) guidelines that apply to Medicare only. However, since these guidelines describe “medical necessity” for Medicare, they would easily apply to any other insurer's requirements.
Illinois Demonstration Project LCD
Illinois Medicare has provided an Adobe Acrobat outline of how to describe the subluxation, PART documentation, and the complete documentation requirements for Initial Exams, and subsequent visits. It also defines "necessity for treatment", what is Maintenance care, proper ICD-9 coding for the subluxation, and the codes that support "medical necessity", broken into short, medium and long duration. This document is clear, short (12 pages), and invaluable. You can locate the LCD (Local Coverage Determination) for your demonstration area here:
Medicare Do's and Don'ts
A step-by-step approach to use of modifiers, and HCFA requirements. This 2 page Acrobat document (93 KB) covers all the most recent information updates amd recommendations. Thanks to the ACA and Susan McClelland for preparing these materials!
THE MEDICARE SAGA
Catch up on the history of our professional struggles with Medicare to gain fair coverage for our patients, and to level the playing field with the other “covered” providers.
The Chiropractor's Guide
Compiled by Lisa Paoli, CMRS of MedOffice Solutions
This 8-page document (also available as a Word document ~ 72 KB) covers proper coding recomendations specifically for Illinois providers. Thanks Lisa! Updated on 6-11-2005
Medicare's Chiropractic Demonstration Project
Federal Register: Jan. 28, 2005; 70 (18): 4130-4132 ~ FULL TEXT
Read the details of the Medicare Chiropractic Demonstration Project, which will test expanded access to chiropractic services for America's senior citizens in a two-year, four-site demonstration project starting April 2005. Review this document for locations and the expanded services chiropractors will be able to provide.
Medicare's Primary Recommendations For HCFA Filing
AT modifier - The AT modifier should be used for every service on all demonstration claims where active/corrective treatment is provided.
DEMO 45 - Demo 45 must be indicated in block 19 of the CMS 1500 claim form for all demonstration claims. For electronic submissions, it would be REF02 (REF01=P4) in the 2300 loop.
Separate Demonstration services (Physical Therapy) from spinal CMT - All claims for demonstration services should be submitted on a separate claim form from claims from spinal CMT (98940, 98941, 98942).
GP modifier - The GP modifier should be used for all therapy services.
25 modifier - When manipulation and E&M codes are billed on the same visit, it is necessary to attach a 25 modifier to the E/M code.
Local Coverage Determinations (LCDs) - Chiropractors must follow local coverage determinations for therapy and other demonstration services—this is particularly important for therapy services. They must also ensure that appropriate diagnosis codes are used for each procedure. Information regarding
LCDs can be found on your carrier websites.
The Acute Treatment (AT) modifier must be attached to the spinal manipulative CPT codes (98940, 98941, or 98942) to distinguish it from unpaid maintenance visits.
Identifies the service as "Physical Therapy". In Illinois I have have been advised that all PT codes must be submitted with BOTH the AT (acute treatment) AND GP modifiers attached like this: Code - ATGP. In non-demonstration areas, GP, coupled with the GY modifier, tells Medicare you know that this is a non-covered therapy.
This indicates to Medicare that you know that this is a non-covered service (like Physical Therapy services outside of the Demonstration Project areas).
This indicates that Medicare will deny a covered service as not reasonable and necessary, and that the provider has an ABN signed by the beneficiary.
This indicates that Medicare will deny a covered service as not reasonable and necessary, and that the provider does NOT have an ABN signed by the beneficiary.
President Bush Signs Legislation Reversing Medicare Physician Fee Cuts
Arlington, Va. - Feb. 8, 2006 President Bush has signed legislation that not only reverses the current 4.4 percent Medicare physician payment reduction, which went into effect on the first of year, but will also provide automatic reprocessing of claims retroactive to Jan. 1, 2006. The legislation was included in the Deficit Reduction Act.
Introduction and Billing Recommendations
Chiropractic Economics March 2005
Chiropractors who are located in any of the four demonstration project areas identified by the Centers for Medicare and Medicaid Services (CMS) will have the opportunity to prove to Congress that chiropractic care is feasible, advisable and beneficial for Medicare recipients.
The Chiropractic Expansion Project
Medicare April 4, 2005
This 20-page Adobe Acrobat file (412 KB) gives you CPT and DX codes that Medicare is going to pay for, and also lists zip codes that are going to be in the project areas. Really alot of information here.
Medicare Revises Requirements For Chiropractic Billing
Center for Medicare and Medicaid ~ FULL TEXT
The Center for Medicare and Medicaid Services (CMS) has issued revised requirements for chiropractic billing of active/corrective treatment and maintenance therapy. As of 10-01-2004 every chiropractic claim (those containing HCPCS code 98940, 98941, 98942) should include the Acute Treatment modifier (AT) if active/corrective treatment is being performed.
Congress Approves Plan to Test Expanded Medicare Access to DCs
The current Medicare program imposes an arbitrary limit on the covered services that can be offered by America's 60,000 doctors of chiropractic and sought by millions of older chiropractic patients. Under current law, a chiropractor may only provide Medicare beneficiaries with a single covered service (manual manipulation of the spine to correct a subluxation) despite the fact that they are licensed in all 50 states to provide additional services that are currently covered under Medicare, including x-rays and other diagnostic tests and physiotherapy services. The ACA has long contended that Medicare's arbitrary limit on chiropractic services is harmful to patients and costly to taxpayers. The four-site, two-year demonstration, will likely have a profound impact in rural and medically underserved areas where beneficiaries will no longer be forced to visit a second or third provider to receive the full range of necessary services.