THREE CODES, how hard can it be?Medicare Phobia
FEATURE
Lisa Maciejewski-West
CMC, CMOM, CMIS, MCS-P
THREE CODES, how hard can it be? Over the years, I can’t tell you how many times I’ve heard that from my Chiropractic clients, and their billing staff. Medicare Part B (the portion of Medicare that covers outpatient physician services) will only cover Spinal Manipulation service/CPT codes 98940, 98941 and 98942 to treat a subluxation of the spine. All other services performed, or referred by a chiropractor are non-covered. So why is it that Chiropractic services have been targeted by the OIG in their annual Work Plan1 almost every year since 2006, and why are Chiropractic Services under such intense audit scrutiny from Supplemental Medicare Review Contractors, such as Strategic Health Solutions?2. Between June 1 to August 31, 2016 a Medical Review of 2555 claims uncovered an improper payment rate to Medicare of 88.3%, and a non-responder rate of 34.8%.3
How is it that we get it so wrong, so often? After all, it’s only three codes. And Medicare even provides a wealth of literature and instruction on how to successfully file Part B claims. Yet, when I’m working with new billing clients, or counseling chiropractors who find themselves in a quagmire of audit, the majority do not know about, or are not aware of the many educational
“From Medicare’s perspective, not knowing is not an excuse.
tools Medicare provides to show them how to successfully file claims that would stand up to audits and recoupments. When a provider enrolls in the Medicare program, Under 42 CFR 489.2 and 411.406, a provider is presumed to “have knowledge of published Medicare coverage rules, regulations, CMS rulings, Medicare coverage policies and acceptable standards within the local community”.4 From Medicare’s perspective, not knowing is not an excuse.
If you are among the doctors who find themselves running for the hills when the word “Medicare” is mentioned, you can, and should turn around. Medicare is the largest insurer of individuals in the US, with over 50 million enrollees. Chiropractors cannot “opt out” of Medicare. You must be enrolled in Medicare to treat a Medicare or Medicare Advantage patient. So, you basically have three choices, enroll as a participating provider, enroll as a non-
par provider, or turn away every Medicare patient, every single time. This would include referring out existing patients who become Medicare eligible. Improvements in health care delivery is causing the life expectancy of Americans to grow every year, and currently 10% of the Medicare population is over the age of 85.5 By avoiding Medicare patients, you are effectively cutting out a large, and ever-growing segment of your local patient population. Many chiropractic offices struggle with new patient acquisition, yet fail to acknowledge that the Medicare aged patient probably has more need of chiropractic treatment than most, as they battle the inevitable wear and degeneration of their musculoskeletal system. And usually they are also among the most compliant and loyal patients. Do you find yourself shying away from a potentially profitable revenue stream because you are afraid of being audited, or think that Medicare billing is “too hard”?
To be successful in billing Medicare, you need to first find, study and apply the rule book. The most cohesive source of information on how to treat a Medicare patient and file Medicare claims is the LCD - Local Coverage Determination document. Almost every state has a Chiropractic LCD, and in the absence of one, there may be a national document available through CMS. Each regional administrative contractor, or MAC is responsible for the
^Some LCD’s even give you an indication of how many visits will be approved based on the diagnosis code.JJ
interpretation of the LCD, so it’s important that you find the LCD that pertains to your State and region. So what does the LCD provide? The LCD will tell you the limitations of coverage, the CPT codes that can be billed, the correct modifiers to use, the way you should document your visits, the requirements for establishing medical necessity, and a complete list of approved ICD-10 diagnosis codes that may be used on Medicare claims. Some LCD’s even give you an indication of how many visits will be approved based on the diagnosis code. For example, the diagnosis code list will be divided in to sections, with verbiage that the codes in each section will generally require “short term, medium term, or long term” treatment. Some of the LCD’s go as far as letting you know how many visits a chiropractic patient can receive in one month and in a calendar year. For example, the LCD of Novitas Solutions, the MAC that administers Part B Chi-
ropractic services in thirteen states, says “Medicare will allow up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulation services per beneficiary per calendar year”.6 The LCD also clarifies the definition of Maintenance therapy, and gives guidelines on when to stop billing Medicare patients under Active Treatment (-AT modifier). “Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or 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”7. The LCD then guides you on how to appropriately apply the use of an Advance Beneficiary Notice (ABN) when informing patients of the transition to supportive care.
The LCD, and other Medicare documents such as the Medicare Billing Policy Manual, and MLN (Medicare Learning Center) articles and publications, leave nothing to the imagination. Medicare billing is very cut and dried. Medicare does not approve of coloring outside the lines. There is no room for interpretation or creativity when it comes to Medicare billing. But if billed correctly, Medicare can be a very profitable revenue source. Think about this. The ONLY service that Medicare covers is Spinal Manipulation to treat a Subluxation. That means that all other services you provide a Medicare patient are cash and carry. You are not even required to bill Medicare for services that are statutorily excluded, or non-covered. Just because you can only be reimbursed for Spinal Manipulation during active treatment, does not mean that you can’t offer Medicare patients other services, such as therapy, massage, supplements, etc. Cash based practices should have a thriving Medicare population, even if Medicare is the ONLY insurance you accept. And remember, if you are a cash only practice, you cannot accept a Medicare patient, unless you are enrolled in Medicare and agree to bill Medicare for patients undergoing Active Treatment to correct a sub luxation. I’ve heard doctors state
that they only treat “maintenance” Medicare patients. But what if that “maintenance” patient presents with a new acute problem? They have an acute injury or flare up of an existing chronic condition? How do you handle? If you only take cash, and are not enrolled in Medicare, at this point you would have to refer the
patient to a Chiropractor who is enrolled. It just doesn’t make good fiscal sense to turn away Medicare patients.
In summary, as a provider enrolled in Medicare you need to know WHEN it is appropriate to bill CPT codes 98940, 98941 and/or 98942 for Active Treatment of a Spinal Sub luxation. Know WHICH ICD-10 codes are approved for billing and the treatment frequency guidelines for those codes. Choose the appropriate CPT code based on the precise levels of subluxation, associated manifestation and how many regions of the spine the levels represent. Know HOW to determine what constitutes Active Treatment and Maintenance. INFORM your patients when they reach Maintenance of their choices for continued spinal manipulation, through the use of the ABN FORM (Advance Beneficiary Notice). INFORM your Medicare patients that all other services provided are non-covered and therefore payable as cash at time of service. DOCUMENT each encounter using the guidelines set forth in the LCD. Remember, your source document (SOAP note) should be an exact mirror of the codes you submit for billing. CHECK your LCD periodically for updates. When the LCD guidelines are followed, and your documentation supports the billed codes, you will find yourself and your patients enjoying the tremendous health benefits that chiropractic care can bring them, without fear of recoupments on audit.
Office of the Inspector General: https://oig.hhs.gov/reports-andpuh li cations/wo rkplan/
Strategic Health Solutions: https://strategichs.com/smrc/
Noridian Medicare: https://med.noridianmedicare.com/ Chiropractic Documentation and CERT Reviews
4. CMS Manual, Provider Certification: https://www.cms.gov/Regulationsand-Guidance/Guidance/
5. AARP Fact Sheet: https './/assets, aarp. org/rgcenter/health/fsl49 jnedicare.pdf
6,7 Novitas Solutions: https://www.novitas-solutions.com/ Search for LCD Chiropractic. Information in article valid at time of publication. LCDs change periodically, so check for accuracy of information at time of review.
References:
LisaMaciejewski-West, CMC, CMOM, CMIS, MCS-P, with 35 years of experience in the chiropractic field, is the president owner of Gold Star Medical, offering professional billing, compliance, and consulting sendees. Lisa holds certifications in coding, management, and compliance. She speaks regularly at local and state associations, as well as for medical and chiropractic organizations nationwide. Lisa can be reached at [email protected] or by phone 866-942-5655.
