here is no area of reimbursement more confounding to doctors of chiropractic than Medicare. One of the major reasons for such confusion is the wide variety of opinions versus facts when it comes to Medicare compliance. Medicare has, perhaps, one of the most clearly documented sets of rules that must be followed. Interpretations of these rules are abundant, but the rules are clearly documented for easy understanding. Imagine my surprise when I got a call from a doctor who said he gave up on Medicare and just charges cash. Sounds good, doesn’t it? However, five months later and with over $100,000 in recouped Medicare denials in his pocket, this doctor began to see that Medicare is not really that difficult.
It seems the biggest reason chiropractors seek help with Medicare is that an office has had staff turnover and has found that the previous employee really was not doing the job they said they were, or the new employee is not performing at the level that was promised. With a lack of standard operating procedure and clearly documented systems, the train is bound to fall off the tracks.
In this case, a new employee began billing Medicare with no real training. Denials ensued, and she kept resubmitting. But with no clear knowledge of how to interpret the denials and without an understanding of what the denial reasons were, appeal after appeal was set aside. Three months later, the doctor quit billing Medicare and wrote off all the money. This one team member almost cost the office $100,000. Because the doctor was not paying attention to a few key principles for Medicare billing, he was within a few months of losing the reimbursement forever. Luckily, he was within the timely appeal and resubmission period. Here are some of the infractions that led to the doctor almost losing $100,000.
Medicare Will Not Pay an Adjustment Without the AT Modifier:
After the scathing Office of Inspector General’s Report of Findings on an audit of chiropractic billing and documentation, rules were set forth to assist offices with informing Medicare when the doctor believes that the care is acute or chronic in nature, and therefore, reimbursable. When an AT modifier is appended to the spinal CMT code, 98940-98942, it indicates to the carrier that the doctor believes it meets the definitions set forth for reimbursable care. If the adjustment code is missing the AT modifier, there must be some other indication, such as a GA modifier, which signifies that the doctor believes Medicare may not pay for this visit and that the patient has been notified. If the GA modifier is missing, there will not be sufficient evidence that the patient has been notified, Medicare will deny with a “contractual obligation” remark code, and the patient cannot be held responsible for the charge.
In this instance, the office failed to bill with the AT modifier. On more than half of the billing submitted, the AT was missing, and there was no indication that the patient had been notified before the treatment that they might be responsible for payment. For that reason, the denials on every visit came back with denial codes that prohibited the office from passing the charge along to the patient. And because the office team was not adept at reading these denial codes, they charged the patient anyway. This led to another incident of throwing up their hands and saying, “Medicare is just too hard.” In fact, using the AT modifier to indicate active treatment is one of the most basic tenants of Medicare billing. The AT modifier is a powerful tool; it alone will often dictate whether the care is reimbursable.
The AT modifier is a powerful tool; it alone will often dictate whether the care is reimbursable.
But the misuse of the code is like playing with fire. Most Medicare audits uncover billing that includes the AT modifier but does not meet the definitions of acute or chronic care. Incompetence, laziness, or miscommunication can lead to incorrect billing, such as leaving the AT modifier on a bill that did not warrant it. This is, unfortunately, abuse of the system. Do not leave the use of Medicare modifiers to team members. Doctors must drive this train and clearly identify on a visit-by-visit basis whether the care is acute or chronic, or if it meets Medicare’s maintenance definition.
If it is maintenance, do not bill with the AT modifier. Remove it to ensure the visit will not be considered for payment. Get the properly executed Advance Beneficiary Notice (ABN) signed and indicate that with the GA modifier on the CMT code, and the denial will come back with proper patient responsibility indicated. It is important to clearly understand Medicare’s definition of maintenance care for proper AT modifier usage: “The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.”
The Mistaken Belief That “If I Am a Cash Practice, I Don't Have to Bill Medicare”
Not only is this a serious misconception regarding Medicare, but also it is extremely dangerous. Because other types of providers, like medical doctors, have options for opting out of Medicare, doctors of chiropractic feel that they should be able to do so as well. However, the Centers for Medicare and Medicaid Services (CMS) has made it very clear to providers that enrollment is mandatory. The following is an excerpt from a letter received directly from a Medicare carrier regarding this matter:
This letter is to inform you that once you have provided a coverable service to a Medicare beneficiary, you are bound by Medicare law. Centers for Medicare and Medicaid Services does not seek to limit or interfere with the right of the beneficiary to obtain medical care from the provider of his/her choice. However, once the physician has provided coverable care to a beneficiary who is enrolled in part V., the law (section 1848 (g)(4) (A) of the Social Security Act) requires that the provider/supplier submit a claim to Medicare; and in order to submit a valid claim to Medicare, the provider/supplier must enroll with the Medicare program.
For the doctor in question, there was no option simply to bill the patient and tell them that Medicare will not pay. Chiropractors, PTs in independent practice and OTs in independent practice have been deemed “non opt-out providers.” This means that they may not opt out of Medicare and must bill Medicare when a patient asks them to. The only true opt-out is when all Medicare patients are turned away and not treated for any coverable or excluded service in the Medicare program.
For this reason, when the bill is submitted to Medicare, it is with the expectation that it will be paid, and if it is not and an AT modifier was used, the office will be expected to follow through with the appeals process. If the office does not, it is tantamount to agreeing with the medical necessity denial, and it indicates that the billing was “just to see if it would be paid.” Be sure to bill for all CMT codes to Medicare, including acute, chronic and maintenance visits. For maintenance visits, if the patient indicates on the ABN form (by selecting Option 2) that they do not wish their care provider to bill it, that relieves the chiropractor of the responsibility, and the patient can be charged.
This office caught the errors and problems before the time limit for filing appeals expired. It is vital that offices set up standard operating procedure for billing and processing Medicare. It is a key part of the billing and collections system and comes with a set of benchmarks that must be followed exactly. Medicare really is not that hard, and in some cases, can be one of the most reliable payers when compared to others. Follow the rules, write a standard operating procedure, and enjoy Medicare reimbursement that is healthy and consistent.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and, since 1983, has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy is known as one of our profession’s foremost experts on Medicare and can be reached at (855) TEAMKMC or info[at]kmcuniversity.com