Medicare and the Chiropractic Practice

As reported in the Oct. 7 issue of DC, representatives from 32 chiropractic organizations, including membership associations, educational institutions, and research and public education foundations, gathered in Orlando in August to seek common solutions and formulate collective action steps to address the new and daunting challenges facing the chiropractic profession. A key focusof the Chiropractic Summit, the third such gathering, was Medicare and the upcoming national debate on systemwide health reform.

The U.S. Department of Health and Human Services, Office of Inspector General (OIG) published a report in 2005 identifying an overall error rate of 67 percent within the chiropractic profession related to Medicare documentation. A follow-up OIG report is anticipated to be released by the end of 2008.The 2009 OIG Work Plan announced it will review chiropractic billings with the active treatment (AT) modifier to determine the appropriateness of Medicare payments for chiropractic claims identified as maintenance therapy.

The summit took place under the auspices of a broad-based steering committee comprised of representatives of the four major participating organizations: Dr. Carl Cleveland III, president, Association of Chiropractic Colleges (ACC); Dr. Lewis Bazakos, former board chair, American Chiropractic Association (ACA); Dr. John Maltby, president, International Chiropractors Association (ICA); and Dr. Jerry DeGrado, president, Congress of Chiropractic State Associations (COCSA). The ACA, ICA, ACC, COCSA and the Federation of Chiropractic Licensing Boards (FCLB) have all been working to provide up-to-date training and education to help doctors of chiropractic document and submit claims accurately and avoid penalties. Misunderstandings regarding the Medicare system have contributed to this problem. 

This is the first in a series of articles on Medicare and issues affecting the chiropractic profession. The following has been adapted from "Medicare Made Simple" as presented by Susan A. McClelland, BS, CCA, FICC (hc) for the ACC on May 3, 2007.

Myth #1: There is a 12-visit cap on chiropractic services.

Fact: There are no caps in Medicare for chiropractic at this time. However, there may be screens or intervals where the carrier will require a review of the provider's documentation as a condition for reimbursing further care.

Myth #2: A doctor of chiropractic can "opt out" of Medicare.

Fact: Doctors of chiropractic cannot opt out of Medicare. Please note: Choosing to be a non-participating (non-par) provider is not the same as opting out.

Myth #3: A doctor of chiropractic may treat Medicare beneficiaries without being registered.

Fact: Doctors of chiropractic may treat Medicare beneficiaries without being registered; however, if a doctor of chiropractic provides a covered service (e.g., spinal manipulation) to a Medicare beneficiary, the DC would then be required to submit a claim to Medicare - and the provider must be registered to submit a claim.

Myth #4: A non-par provider does not have to bill Medicare.

Fact: Being non-par does not exempt the provider from having to bill Medicare.

Myth #5: A non-par provider will never be audited or have a claim reviewed.

Fact: Any Medicare claim submitted can be audited/reviewed, regardless of provider status. The participation status of the provider does not affect the probability of this occurring.

Myth #6: Non-par providers do not have the same documentation requirements as par providers.

Fact: Medicare has documentation requirements for chiropractic care, regardless of provider participation status.

Myth #7: Maintenance care is not a covered service under Medicare.

Fact: The service of spinal manipulation is a covered service under Medicare, regardless of the beneficiary's phase of care (acute, chronic, or maintenance); however, maintenance care, although "covered" is not "reimbursable," as it is considered by Medicare to be not reasonable and necessary. Acute, chronic and maintenance adjustments are all "covered," but only acute and chronic services are considered active care and, therefore, may be reimbursed. A provider must submit a claim for all covered services, regardless of whether they are reimbursable. This includes maintenance care.

Myth #8: An Advance Beneficiary Notice (ABN) should be signed once for each beneficiary; it will then apply to all services and all visits.

Fact: Blanket and/or generic ABNs are forbidden. The decision to deliver an ABN for covered services must be based on a genuine expectation that Medicare will deny payment for the service due to it being not reasonable and necessary. A doctor of chiropractic should use an ABN for "maintenance care" spinal adjustments. Please note: There is a new ABN available, which will be mandatory as of March 1, 2009. The new form and its instructions can be found at www.cms.hhs.gov/BNI/02_ABNGABNL.asp#TopOfPage.

Myth #9: Medicare has unreasonable documentation requirements.

Fact: Medicare has specific documentation requirements, but nothing extraordinary. Regardless of whether a patient is a Medicare beneficiary, providers should exercise appropriate "standards of care" with thorough documentation of each beneficiary encounter.

Myth #10: Chiropractors can offer free X-rays to Medicare beneficiaries.

Fact: "Inducements" are strictly forbidden for Medicare beneficiaries. Free examinations, X-rays and other valuable incentives could lead to accusations of fraud or abuse.

Dr. Carl Cleveland III, Dr. Ritch Miller, Dr. Frank Nicchi, Dr. Rob Scott, Susan McClelland, Ron Hendrickson, Paul Lambert, Kim Drigger, Sandy Mooney, David O'Bryon and Joe Baker serve on a subcommittee of the Chiropractic Summit and contributed to this article.

The subject matter in this article is discussed in a recent CMS publication (www.cms.hhs.gov/MLNMattersArticles/downloads/SE0749.pdf). For more on Medicare documentation, visit:

• www.acatoday.org/Medicare
• www.chiropractic.org/index.php?p=news/ntl_medicare_conf_2008
• www.chirocolleges.org/medicare_articles.pdf