The following information was extracted from a Medicare Learning Network (MLN) Matters publication. Some additional links have been added as a helpful resource for ACA Members.
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Addressing Misinformation Regarding Chiropractic Services and Medicare
Provider Types Affected
Providers submitting claims to Medicare contractors (carriers, and/or Part A/Part B Medicare Administrative Contractors (A/B MACs)) for Chiropractic services provided to Medicare beneficiaries
Provider Action Needed
This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to correct misinformation in the chiropractic community relating to Medicare and its regulations as they relate to chiropractic services. This article is informational only and represents no changes to existing Medicare policy.
In order to correct misinformation about Medicare and its regulations which exist in the chiropractic community, the American Chiropractic Association (ACA) works to check the validity of all claims and provide accurate information based on the Medicare manual system maintained by CMS, as well as information in regulatory and statutory language. CMS is providing this special edition article which it hopes will clarify certain issues, around which there may be some confusion. The specific issues being addressed are:
MISINFORMATION #1: There is a 12 visit cap or limit for chiropractic services.
Correction. There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5. (This manual is available at http://www.cms.hhs.gov/manuals/IOM/list.asp on the CMS website.)
There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation ), but caps/limits are not allowed.
The Social Security Act (Section 1862 (a)(1); see http://www.ssa.gov/OP_Home/ssact/title18/1862.htm on the Internet) provides that Medicare will only pay for items or services it determines to be "reasonable and necessary," and if those items or services can be shown to be “reasonable and necessary,” then those items or services are covered and will be paid by Medicare.
MISINFORMATION #2 . If you are a non-participating (non-par) provider, you do not have to worry about billing Medicare.
Correction. Being non-par does not mean you don’t have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties.
A non-par provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.
It is important to note that non-par providers may choose to accept assignment, therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS 1500 claim form. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.
Whether or not a non-par provider chooses to accept assignment on all claims or on a claim-by-claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule.
You can find a copy of the Medicare Participating Provider Agreement at http://www.cms.hhs.gov/cmsforms/downloads/cms460.pdf on the CMS website. The form contains important information regarding the participation process and the annual opportunity you have to make or change your participation decision.
Additional information is available in the Medicare Benefit Policy Manual (Chapter 15; Covered Medical and Other Health Services) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS website and the Medicare Claims Processing Manual (Chapter 12; Physician/Nonphysician Practitioners) at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf on the CMS website.
MISINFORMATION #3 . If you are a non-participating (non-par) provider, you will never be audited nor have claims reviewed, etc.
Correction. Any Medicare claim submitted can be audited/reviewed; the non-participating (non-par) or participating (par) status of the physician does not affect the possibility of this occurring. CMS audits/reviews are intended to protect Medicare trust funds and also to identify billing errors so providers and their billing staff can be alerted of errors and educated on how to avoid future errors. Correct coverage, reimbursement, and billing requirements are readily available to
assist you in understanding Medicare requirements. This information is in Medicare manuals that are at http://www.cms.hhs.gov/Manuals/ on the CMS website. In addition, an excellent way to stay informed about changes to Medicare billing and coverage requirements is to monitor MLN Matters articles, such as this one, which are available at http://www.cms.hhs.gov/MLNMattersArticles/ on the same site.
MISINFORMATION #4: You can opt out of Medicare.
Correction: Opting out of Medicare is not an option for Doctors of Chiropractic. Note that opting out and being non-participating are not the same things. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out.
For further discussions of the Medicare “opt out” provision, see the Medicare Benefits Policy Manual (Chapter 15, Section 40; Definition of Physician/Practitioner) at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf on the CMS website.
MISINFORMATION #5 . You should get an Advance Beneficiary Notification (ABN) signed once for each patient, and it will apply to all services, all visits.
Correction. The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The ABN then allows the beneficiary to make an informed decision about receiving and paying for the service. Should the beneficiary decide to receive the service, you must then submit a claim to Medicare even though you expect the beneficiary to pay and you expect that Medicare will deny the claim.
For further information, see the Medicare Claims Processing Manual (Chapter 30) at http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf and the Medicare Benefits Policy Manual (Chapter 15) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS website. Also see “What Doctors Need to Know about the Advance Beneficiary Notice (ABN)” athttp://www.cms.hhs.gov/MLNProducts/downloads/ABN_READERS.pdf on the CMS website.
MISINFORMATION #6 . Maintenance care is not a covered service under Medicare.
Correction. Spinal manipulation is a covered service under Medicare, no matter which phase of care you may be in; however, maintenance care is not medically reasonable and necessary and therefore not reimburseable by Medicare. Acute, chronic, and maintenance adjustments are all “covered” services, but only acute and chronic services are considered active care and may, therefore, be reimbursable. Maintenance therapy is defined (per Chapter 15, Section 30.5.B. of the Medicare Benefits Policy Manual)) as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.
See MM3449 (Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3449.pdf on the CMS website. This article contains important information on completing claims and how to identify acute and chronic adjustments as opposed to maintenance adjustments. The article also recommends you consider issuing an ABN to the Medicare beneficiary when you provide maintenance services. Additional details are available in the Medicare Benefits Policy Manual, Chapter 15, Section 30.5 (Chiropractor’s Services) at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf on the CMS website.
MISINFORMATION #7 . Non-par providers do not have the same documentation requirements as par providers.
Correction. Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements.
Specific details regarding documentation are in the Medicare Benefit Policy Manual (Chapter 15, Sections 30.5 and 240) at http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf on the CMS website. Also, see the Medicare Claims Processing Manual (Chapter 12, Section 220) at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf on the CMS website.
If you have any questions regarding chiropractic issues and Medicare, please contact your Medicare carrier or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.