Medicare and Chiropractic: Clearing Up Some Billing Misconceptions

Considering the myriad of Medicare questions I receive, it is worthwhile to address a few of the prevailing misconceptions. Rather than a single question and answer, as is the usual format of this column, here are nine truisms regarding Medicare and chiropractic:

1. There is not a 12-visit limit to Medicare for chiropractic services. The limits of care are based on the specific medical necessity of the primary subluxation and its secondary neuromusculoskeletal diagnosis. While Medicare does monitor the severity of the secondary diagnosis and assign a "screen," there is no specified or exact limit. The bottom line is that the more severe the secondary, the greater amounts of care allowed before any request of additional information.

2. Medicare will pay for both acute and chronic conditions as long as there is documentation or expectation of functional improvement. Acute subluxation - A patient's condition is considered acute when the patient is being treated for a new injury, identified by X-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in or arrest of progression of the patient's condition. Chronic subluxation - A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but when the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

3. Nonparticipating (nonpar) providers are required to bill for services. All covered services under chiropractic (spinal manipulation) must be billed to Medicare. The different option that a nonpar provider has over a participating (par) provider is the former does not have to accept assignment or those claims and may bill the patient up to the limiting charge. [Note: This does not apply in states like Pennsylvania that have the Medicare Overcharge Measure (MOM) law, wherein the nonpar amount prevails for nonpar providers.]

4. Nonpar providers are audited just as par providers are. There is no protection from a Medicare audit by being nonpar. Audits are triggered by any provider billing claims that fall out of the norm for chiropractic claims, whether par or nonpar. Further audits may be conducted at random, though certainly factors that make you stick out among your peers will draw greater attention.

5. Nonpar providers must document services in the same manner as any provider of Medicare services. Being par or nonpar is irrelevant in reference to documentation of chiropractic services. In fact, in reference to #4, nonpar providers who have or had this belief typically have more difficultly justifying their services, as they document with too little information to support medical necessity.

6. Chiropractors may not opt out of Medicare. Thisis simply not an option for doctors of chiropractic. Being nonpar is not "opting out," but designating oneself as a Medicare provider nonpar. In simple terms, chiropractors must belong to Medicare to treat Medicare patients.

7. Advance Beneficiary Notices (ABNs) should not be used as routine documents for patients to sign on their initial visit. However, they must be used when there is a genuine belief or reasonable expectation that Medicare will deny or not pay for the service on a specific visit or series of visits. In other words, a blanket ABN at the beginning of care is not sufficient or compliant.

8. Medicare claims are not difficult; they are simply different from health insurance claims. When not done in Medicare's format, claims are denied. However, once the differences are understood and billed correctly, Medicare can be a great asset to supporting a successful practice. Bear in mind that essentially everyone over age 65 has Medicare, which means the baby boomer generation is now becoming Medicare eligible. In 2007, the first baby boomer filed for Social Security and there are reports that 5,000-10,000 additional boomers become eligible every day. And considering the baby boomer years span 1946-1964, that is 18 years of substantial growth.

9. Medicare payment is what it is. I will refrain from stating it is "good." While we all would want higher reimbursements (Who doesn't?), the average fees for chiropractic services for manipulation are $30-$36 per visit. This is far better reimbursement than under many of the managed care plans chiropractors routinely fight to join. Furthermore, that dollar amount is for spinal manipulation only; other services may be billed to the patient or covered by a secondary insurance plan.

Consider the potential volume from #8 and my experience with the doctors I teach seminars to and consult, who report they routinely are allowed 20-30 visits per year by Medicare on most of their patients. If you sit outside of Medicare, you are missing out not only on these reimbursements, but also the potential to help someone who would otherwise be limited to hearing "You're getting old," "You have to live with it," "Medication can help temporarily, but will become less effective over time," and so on.