Medicare demo project
New opportunities for seniors and chiropractors
By ritch miller, dc

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.

Starting in April 2005, you will be able to provide expanded reimbursable care to Medicare recipients through the Chiropractic Demonstration Project, part of the Medicare Modernization Act of 2003 (MMA).

If you are among the many chiropractors in the demonstration area, you may be wondering: “How is this project going to change my practice?”

The short answer is: Nothing changes, except billing.

Billing, however, does change — and the requirements to get reimbursed for procedures covered by the demonstration project will create extra work for your billing department.

Beginning in April 2005, you will be able to bill Medicare carriers and be reimbursed for some Part B medical, radiology, clinical lab and therapy services. These are services related to the treatment of neuromusculoskeletal conditions that you already provide for your Medicare fee-for-service patients. Of course, you can only bill and seek reimbursement for these services according to your state scope-of-practice laws and within Medicare rules.

The extra work involves completing additional forms. Demonstration project services must be billed separately from the spinal CMT services that are already covered under Medicare.

When billing for services that are available exclusively under the demonstration, you must use a separate claim form and include a special “demonstration code” (Demo 45) in box 19 on a separate CMS 1500 claim form.

The demonstration number (Demo 45) must be inserted in box 19 for the expanded benefits to be paid. CMT services that are already covered by Medicare must be billed on a separate 1500 form with box 19 blank. It is important to separate these services onto the two different claim forms, since as this is how CMS will track the demonstration progress.

It is expected that the number of chiropractic Medicare visits will remain near the same level that it has been historically. Of course, it is also expected that there will be the usual small percentage of growth inherent and already in the system caused by a normal increase in the continued rise of the number of eligible beneficiaries and to a lessor amount, the increase in the number of chiropractic providers.

More specifically, you can bill and seek reimbursement from Medicare for:

• Evaluation and management (E&M). Under this demonstration project chiropractors will be reimbursed for Office and Outpatient Evaluation and Evaluation and Management (E&M) services delivered for neuromusculoskeletal conditions. You will be allowed to bill Medicare for both an E&M visit and for treatment the first time you assess a new patient, as well as for current patients in instances such as when the patient has a new condition, an exacerbation or a recurrence of the current condition or needs a reassessment midway through treatment.

Chiropractors billing Medicare under this project must follow the same documentation guidelines that medical physicians follow for E&M services. These guidelines are quite complicated, and I suggest you refer to CMS guidelines for a complete discussion of their proper use.

These guidelines can be found at: www.cms.hhs.gov/medlearn/emdoc.asp.

You can also find additional E&M guidance in the Medicare Claims Processing Manual, publication 100-04, Chapter 12, Section 30. This manual may be accessed at: www.cms.hhs.gov/manuals/104_claims/clm104index.asp.

• Spinal CMT codes. Spinal CMT services are not considered part of the demonstration and therefore must be billed on a separate CMS 1500 form — the same as you have been billing Medicare — as discussed earlier in the article.

CMT codes include both manual adjustments and cognitive work you perform in the treatment of the patient.

Work performed for adjustive or manipulative treatment includes pre-service, intra-service and post-service. These services do not qualify for the billing of an additional E&M code, since they are already part of the CMT. The same guidelines apply to the CMT codes that have always applied.

Chiropractic manipulation codes (CMTs) include a brief pre-manipulation E&M assessment, so you should not bill E&M with subsequent visits unless the patient’s condition requires a significant, separately identifiable E&M service.

• Extraspinal manipulation. You will now be allowed to bill Medicare for CMT code 98943 — extraspinal manip-ulation. This is a demonstration code and must be billed on the demonstration claim as previously explained. Reimbursement levels can be found in the Medlearn Matters article referenced near the end of this article.

• Ancillary services. Demonstration coverage also includes other ancillary services you are allowed to perform by your state scope-of-practice law. These procedures include electrotherapy, ultrasound, TENS and other services that are medically necessary for the treatment of neuromusculoskeletal conditions.

At the time this article was written, you will be subject to the same coverage and payment rules that other physicians and physical therapists must follow. You must also follow physician requirements for “incident to” services. More complete information can be found at: www.cms.hhs.gov/manuals. Search under: 102_policy/bp102s. Also go to www.cms.hhs.gov/medlearn. Search under: SE0441.

• Clinical lab services. You will be able to perform or order a number of clinical laboratory services, which are listed in Medicare’s clinical lab fee schedule.

All tests you order and the laboratory you use must comply with the Clinical Laboratory Improvement Amendment (CLIA) program. You are subject to clinical laboratory state practice requirements and also must comply with the Stark requirements regarding limitations on physician self-referrals. As with all services performed or ordered you must document medical necessity in the patient record.

• X-rays and other diagnostic tests. Under this project, you will also be allowed to bill Medicare for plain x-rays, EMGs and nerve conduction studies. You will be able to order MRIs and CT scans under this project; however, Medicare will not reimburse chiropractors to interpret them.

PROPER DOCUMENTATION A REQUIREMENT

For this demonstration project to be a success, all documen-tation must be properly done. This is not a change. Proper Medicare documentation has always been a requirement. To assure accurate coding, review CMT codes and refer again to CMS guidelines (NCD, national coverage determination) and your own local carriers (LCD, local coverage determination).

Your conscientious participation in this demonstration project is important to 32 million Medicare beneficiaries. To assure its success:

• Provide good care. All billed and reimbursed care must be medically necessary. Medical necessity must be documented per Medicare requirements.
• Fill out forms correctly. You don’t want to slow down the reimbursement process.
• Document carefully. Review your documentation procedures and upgrade them as necessary.
• Code properly. Get up-to-date, accurate coding manuals and refer to them often. Train yourself and your staff.

Use caution when choosing your references and from whom you get your training. You may be aware that much misinformation, disinformation — and yes, even fraudulent information — is circulating. I can’t think of anything that would do more harm to this demonstration than a few misguided clinics using “bad” information.

Go to the source — Medicare. More complete and inclusive information can be found at www.cms.hhs.gov/medlearn. Search under: SE0514.

Now it is up to you. Do your part to make this demonstration a success. You owe it to your Medicare patients, you owe it to all Medicare patients, and you owe it to chiropractic.

Ritch Miller, DC, has been in active practice in Omaha, Neb., since 1988. He has been the Nebraska chiropractic representative on the Nebraska Medicare Carrier Advisory committee since 1993. Dr. Miller is also the Nebraska Delegate to the American Chiropractic Association and the National Chairman of the Medicare Committee for the American Chiropractic Association. He can be contacted at ACAMEDICARE@aol.com.