When confronted with ever-evolving coding and documentation requirements, and the stiff penalties for non-compliance, it’s not surprising that many chiropractors would happily opt out of Medicare if given the opportunity.
Many myths surround Medicare reimbursement, leaving chiropractors unsure as to what their requirements are.
This confusion is compounded by the fact that, while it is a federal program, Medicare is administered regionally. Policies can vary from state to state, requiring providers to be aware of the local policies that may impact their practice. The following are some of the most common myths, an understanding of which should bring some clarity.
Myth No. 1: There is a 12 visit cap on chiropractic services.
While there are no set caps or limits for chiropractic services, most Medicare Administrative Contractors (MACs) have review screens. A review screen is a set number of visits (often 12), at which point the MAC will require a review of documentation proving the ongoing medical necessity of the care delivered prior to allowing further care. This screen requires chiropractors to objectively document positive improvement in patients’ symptoms and function at regular intervals. These re-examination intervals should not exceed 30 days.
Medicare requires chiropractors to update their treatment plan and diagnosis based upon these examination findings.
Myth No. 2: Nonparticipating providers do not have to bill Medicare.
Nonparticipating (non-par) providers have chosen not to accept the assignment of benefits from Medicare. While non-par providers may receive payment directly from their patients, they are still required to submit a bill to Medicare for covered services. Only acute spinal manipulation is a covered service under Medicare. This is referred to as the “Mandatory Claim Submission Rule.”
Not billing Medicare for acute spinal manipulation means the provider could face penalties. An exception to this rule is permitted when a beneficiary signs an Advance Beneficiary Notice of Noncoverage (ABN) with Option No. 2 selected.
Myth No. 3: Nonparticipating providers are never audited by Medicare.
The participation status of a provider does not affect the possibility of claims being audited or reviewed.
Both participating and non-par providers should expect to have their claims audited for compliance with documentation and coding requirements. Regular training for providers and billing staff to keep up to date on how to avoid errors is an important way to stay informed about changes to Medicare’s billing and coverage requirements.
Myth No. 4: Chiropractors can opt out of Medicare.
This may be one of the most widespread and perilous of all of the Medicare myths. Chiropractors, unlike other healthcare providers, may not opt out of Medicare but can decide whether to be participating or non-participating.
Chiropractors must bill Medicare for all acute spinal manipulation.
Chiropractors are not required to bill Medicare for non-covered services, which include X-rays, examinations, physiotherapeutic modalities, exercise therapy, and maintenance spinal manipulation. Attempting to opt out of Medicare by not submitting bills for covered services places the provider in a precarious situation.
Myth No. 5: Chiropractors should have all patients sign an ABN for all services provided.
The decision to have a patient sign an ABN must be based on the chiropractor’s expectation that Medicare will not consider the service to be medically necessary and will not pay for it. Medicare considers spinal manipulation acute if there is an expectation of significant improvement in symptoms and function. Once a patient has reached a plateau in improvement, spinal manipulation is no longer considered acute.
The period between the initiation of care and the plateau in symptom- atic and functional improvement is considered an episode of care. At the conclusion of an episode of care, chiropractors may recommend maintenance care, which is not considered a covered service under Medicare.
Should a patient decide to follow the chiropractor’s recommendation and receive maintenance care, the patient should sign an ABN allowing the chiropractor to bill the patient directly for the services provided.
The ABN has three option boxes, and the patient must choose one of the boxes before signing the form for it to be considered valid. An ABN may be signed once for repetitive services (such as monthly spinal manipulation) for up to one year, after which time a new ABN must be signed.
Option 1: A patient signing this option agrees to pay out of pocket for the services in question and requests the chiropractor to file a claim for the services to Medicare. Some Medicare patients have secondary insurance and need a denial from Medicare to enable them to submit to their secondary insurance plan.
Option 2: A patient signing this option agrees to pay out of pocket for the services in question and requests the chiropractor to not file a claim for the services to Medicare. The patient may change his or her mind at a future time and request that the claim be submitted.
Option 3: Medicare can also provide patients with the bizarre third option, meaning the patient neither chooses to receive nor pay for the service in question. This would likely be an unusual occurrence.
Myth No. 6: Maintenance care is not a covered service under Medicare.
In another hair-raising definition likely to bewilder most chiropractors, Maintenance care is considered a covered service by Medicare (falling within the classification of spinal manipulation), it is not however, considered medically reasonable and necessary, and is not reimbursable. To further complicate the issue, Medicare defines maintenance therapy 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 the deterioration of a chronic condition.”
It would seem that Medicare’s definition of maintenance care is exactly where the federal government should be investing tax dollars to protect the health and wellness of the American public.
Myth No. 7: Non-par DCs don’t have the same documentation requirements as par providers.
The documentation requirements are identical for all chiropractors regardless of their status as participating or non-par providers. Objectively documenting the positive outcomes of chiropractic care is essential for the inclusion and potential expansion of chiropractic coverage under Medicare. All chiropractors should take their documentation requirements with the utmost seriousness.
Take a proactive approach toward continuing your education on this hot topic and review your specific state statutes and regulations concerning Medicare.
Mark Sanna, DC, ACRB Level II, FICC, is a member of the Chiropractic Summit, the ACA Governor’s Advisory Cabinet, and a board member of the Foundation for Chiropractic Progress. He is the president and CEO of Breakthrough Coaching and can be contacted at 800- 723-8423 or through mybreakthrough.com.