How to best navigate billing for Medicare patients and create your Medicare chiropractic billing guide
For many chiropractors, Medicare patients are an important part of the practice. Getting Medicare billing right takes some care and consistency.
Here are some guidelines to create your Medicare chiropractic billing guide:
Get coding and documentation right
Medicare does cover chiropractic care, but the program is very specific about how to establish medical necessity and demonstrate that your diagnosis fits your patient’s needs. If you don’t follow these rules, your claim may be denied or you could even risk accusations of attempted fraud.
Getting this wrong can have severe consequences. So, is accepting Medicare still worth it? It is — as long as you get the coding and documentation right. Help yourself by creating your Medicare chiropractic billing guide.
With Medicare, only three different Current Procedural Terminology (CPT) codes are permitted. Providers must carefully show that a diagnosis of subluxation is clearly presented by the patient’s symptoms, health history, examination results and applicable lab work. If you can’t establish necessity sufficiently for CMS, your claim will likely be rejected.
To have a successful claim, you need to be absolutely sure that you have the correct details and documentation.
On initial visits, you’ll need to show information about your patient’s condition. For instance:
- History: The primary complaint your patient has and any applicable symptoms that motivated them to seek treatment. Also, your patient’s family history and personal medical history if these are related and relevant to the case.
- Present illness: Next, you’ll need to describe the illness your patient has now. Include:
- How trauma to the patient’s skeletal system happened
- Description of the symptoms
- Location, onset, duration, intensity, frequency, and radiation of any symptoms
- What aggravates or relieves symptoms
- Previous treatments, medications, interventions tried and any secondary complaints
- Symptoms that brought the patient to your office
- Physical exam: If, during the physical exam, you identify subluxation that requires intervention and treatment, you’ll need to show that your patient’s condition includes two or more additional criteria. These criteria must also be something you can document properly:
- A: Asymmetry or misalignment you observe or notice through imaging. Also, through static palpation.
- R: Abnormal range of motion you diagnose through observation or measurement in a section or segment.
- T: Tissue tone, texture or temperature abnormality in the soft tissues of the body.
- P: Pain or tenderness. You must be able to describe and document the pain specifically with information about intensity, location, and quality. Simply noting “pain” in the documentation without providing further information isn’t acceptable.
- Diagnosis: The claim will only be covered if the primary diagnosis is subluxation. Be prepared to sufficiently document this claim with specifics about the area of the spine involved or the specific bones experiencing the problem.
- Treatment plan: Here, you’ll need to provide detail about your treatment plan. For instance:
- How much care the patient needs. An estimated number of visits and a plan for how frequently care is needed.
- Specific goals for treatment.
- Objective benchmarks that will help you determine if treatment is successful.
- Date of the initial treatment
- The full medical record
- History: Review the primary complaint and note any changes in the patient’s condition since the last visit. If relevant, include a systems review.
- Physical exam: Examine where the diagnosis is relevant and assess any changes in the exam. Determine if the treatment has been effective thus far.
- Treatment documentation: If any additional treatment is given, be sure to document it now.
Of course, diving into Medicare billing and documentation is something you’ll want to do very carefully, and the specifics of your own claims may differ, but this provides you with a general overall picture of what a Medicare claim might look like to create your Medicare chiropractic billing guide
One of the most important things here is to be sure you carefully establish medical necessity for any treatments you provide. Stretching the medical necessity standards and showing inaccurate or exaggerated documentation will not help your case. It’s easy to make mistakes here — but if you learn how coding and documentation for Medicare works, you can reduce the likelihood of error.
With the right coding and documentation, you’re well on your way to improving your Medicare approval odds. Keep learning more about the Medicare program to find out more information you can use in your practice.
MLN Matters. “Medicare coverage for chiropractic services–Medical record documentation required for initial and subsequent visits.” CMS. Accessed: June 2019. Retrieved from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1601.pdf