Every CA, whether new or a seasoned professional, can use a refresher Medicare benefits filing course

Medicare is based on federal legislation, which means that, for the most part, coverage and filing procedures are uniform for every state. Its benefits are available for individuals more than 65 years old or for the disabled at any age. Dependent spouses qualify at 62 years. Medicare is thus automatic for anyone receiving social security income (SSI) benefits when they turn 65. Individuals not receiving SSI benefits must file for coverage within 3 months of their 65th birthday.

Benefits are available on the first day of the month in which the beneficiary turns 65 or the first day of the previous month if the birthday falls on the first day. Make sure the insurance staff keeps a tickler file on all patients approaching their 65th birthday, and remember benefits become available at the beginning of the month of their birthday, not after their birthday.

Handle with Care
There are three distinct parts to Medicare: Part A—hospital coverage, Part B—outpatient doctors’ visits (chiropractic) and skilled-nursing home care, and Part C—Medicare HMO coverage.

Part B has a $100 annual deductible. Deductibles are met with covered services allowable amounts only. Since only manual manipulation is a covered service under Medicare, only the allowable amount set by Medicare will be applied toward the deductible. For example, if your office files a claim for $35 for manipulation and the allowable amount is only $24.35 for your locality, then only $24.35 will be applied toward the deductible.

Remember that Medicare patients can meet their deductible by receiving any Part B benefit from all doctors. Ask your patients whether they are receiving health care from other doctors. (Hospital stays do not meet Part B deductibles.) Also, many patients carry a Medicare supplement that may pay for Part A deductibles but not Part B. Do not assume that when a patient says the policy covers everything that Medicare does not, this means deductibles. For chiropractic services, most supplemental policies pay only the coinsurance on the Medicare allowable amounts. Secondary policies may also cover some noncovered services.

Medicare supplemental policies cover only what Medicare allows and will not pay for unapproved services. These policies usually pay only the coinsurance of the Medicare allowable amount. For example, if Medicare allowed $25 for an adjustment and paid 80%, Medicare would pay $20. If the patient had a supplemental policy, it would pay the 20%. However, if the claim was deemed not medically necessary, then the supplemental policy would not pay anything on the claim.

A secondary policy is one that patients have in addition to Medicare. These policies pay based on their own coverage benefits, regardless of what Medicare allows. The secondary policy deducts Medicare payments from any benefits available. It is also a great resource for coverage on items such as examinations and therapy. Unfortunately, most Medicare beneficiaries have supplemental policies, not secondary ones. Remember, Medigap policies are always supplemental. Medigap is the term used by Medicare for all supplemental policies for which Medicare will automatically forward the claim forms for participating doctors.

All Things Provided
All doctors are Medicare providers unless terminated from the system. DCs cannot opt out of Medicare. Participating providers have contractually agreed to accept assignment on all Medicare cases. This means that the provider agrees to bill Medicare and wait for 80% of allowable fees to be paid directly by Medicare.

Nonparticipating providers (NPPs) must bill Medicare when covered services are provided. However, NPPs can choose when and whom they will accept for assignment. NPPs can collect 100% of their limiting fee (set by Medicare) directly from patients. Medicare will then reimburse patients 80% of the nonpar allowable fee. Or NPPs can accept assignment from Medicare (wait for Medicare to pay 80% of the nonpar allowable fee directly to the provider) and collect only 20% of the nonpar allowable fee from patients.

Providers cannot collect their normal fees on covered services provided to Medicare patients. There is no such thing as not dealing with Medicare. It is important to know whether the DC is participating or nonparticipating, because the amount of coinsurance that can be collected from the patient is based on the participation status of the doctor.

Also, it is extremely important for NPPs to know the difference between assigned and nonassigned claims. The front desk CA must know the correct amount that can be collected from the Medicare patient, and these coinsurance amounts change based on whether the claim is assigned. For example, if an NPP has a limiting amount of $30 and a nonpar allowable amount of $25, and the provider accepts assignment on a claim, the front desk CA needs to collect 20% of the nonpar allowable fee ($5), not 20% of the limiting fee (20% of $30 is $6). Collecting more than the correct coinsurance would be a Medicare violation, which could result in fines.

Medicare fines start at $10,000 per incident, which means every time a violation occurs can be seen as an individual violation. If the above example occurred and the patient came in three separate days, the fine would be $30,000.

It is also illegal to waive a Medicare patient’s coinsurance or entice a beneficiary to use Medicare benefits.

There are certain instances when other insurance will pay before Medicare (use Medicare fees for manipulation whether Medicare is primary or secondary): 1) the beneficiary or beneficiary’s spouse is actively employed; 2) the beneficiary is disabled and under age 65, with employer benefit coverage; 3) there is automobile, no-fault medical, personal injury protection, or third-party liability involvement; 4) black lung program benefits are paid by the Department of Labor Black Lung Program; 5) the beneficiary is entitled to veterans benefits; 6) the beneficiary is injured on the job and covered under workers’ compensation; and 7) individuals are entitled to Medicare on the basis of end-stage renal disease (ESRD).

DCs can now adjust patients in settings other than the office. However, when a covered service of manual manipulation occurs outside of the office, a site-of-service (SOS) discount will be deducted from the reimbursement. When the service is performed in the office, the place of service (POS) code is 11; 12 is for a home visit and 32 is for a nursing home visit. Usually, the SOS discount is approximately $5 less than the normal allowable fees.

Necessity of Treatment
Medicare covers only manual manipulation of the spine (98940, 98941, and 98942 CPT codes) and pays only when there is a significant health problem in the form of a neuromusculoskeletal condition that has a direct therapeutic relationship to a specific subluxation (secondary diagnosis). Plus, adjusting this specific subluxation must also result in recovery, or improvement, of function. Subluxations must be demonstrated by either x-ray or physical exam. X-rays are not required if proper evaluation is documented.

For manipulation to be a covered service, there must be a documented ailment consisting of: 1) pain/tenderness (evaluated in terms of location, quality, and intensity), 2) asymmetry/misalignment (identified on a sectional or segmental level), 3) range of motion (ROM) abnormality (changes in active, passive, and accessory segmental mobility), and/or 4) tissue tone changes in the characteristics of contiguous or associated soft tissue, including skin, fascia, muscle, and ligament. To demonstrate a subluxation based on a physical examination, two of the four above-mentioned findings must be present, one of which must be either the asymmetry/misalignment or ROM abnormality.

Afterward, a diagnosis of a subluxation (839 codes) or segmental dysfunction (739 codes) must be given. While the Medicare Act allows benefits to be paid under either set of codes, individual state carriers have a preference (check with your carrier to see which codes are required in your state). Also, a symptom must be diagnosed within each region to demonstrate the medical necessity of the adjustment.

Providers must use distinct modifiers when billing services to Medicare carriers. These modifiers should be standard nationwide.

GA modifiers: To indicate that Medicare is expected to deny a covered service as not reasonable and necessary, and there is an advanced benefits notice (ABN) signed by the beneficiary.

GZ modifiers: To indicate that they expect that Medicare will deny a covered service as not reasonable and necessary and do not have an ABN signed by the beneficiary.

GY modifiers: To indicate that the item billed is statutorily noncovered or is not a Medicare benefit. DCs must use this modifier if they are billing any service other than manual manipulation to a Medicare carrier.

Always check to ensure that Medicare claims have a primary diagnosis of a subluxation and appropriate symptom. Verify that each CPT code has the correct modifier and the correct POS code. Have patients sign an ABN when appropriate.

Providers are required to have Medicare patients sign an ABN before services if Medicare is likely to deny payment for an otherwise covered service. ABNs are not required for noncovered services. ABNs notify beneficiaries about receiving services for which they may have to pay out-of-pocket. A new ABN (CMS-R-131) form was adopted last year and became mandatory as of October 1, 2002. Obtain a copy via the Web: www.cms.gov/ medicare/bni/CMSR131G_June2002.pdf.

Since the the final regulation was delayed past November 1, 2002, Medicare did not implement the 2003 fee schedule until March 1, 2003. Services provided in January and February 2003, and processed before March 1, should be paid at the 2002 fee schedule rates. Services performed after March 1 will be paid at the slightly higher rate (1.6% increase over the 2002 fees). To obtain the 2003 fees for your locality, visit www.cms.hhs.gov.

All in the Family
It is illegal for providers to file a claim to Medicare when treating immediate relatives: husband and/or wife; natural or adoptive parent, child, and sibling; step-parent, -child, -brother, and -sister; in-laws: father, mother, son, daughter, brother, and sister; grandparent and grandchild; and spouse of grandparent and grandchild. Furthermore, a step-relationship exists even after the marriage on which the relationship is based is terminated through divorce or death. A brother- or sister-in-law relationship does not extend to the in-laws by marriage (ie, in-laws of wife or husband providers). A father- or mother-in-law relationship does not exist between providers and their spouses’ step-father or -mother.

Another exclusion that many providers overlook is the common-abode relationship. Providers are also prohibited from filing Medicare benefits for any person who is living in the provider’s home, whether related or not (ie, live-in babysitters or domestic help).

The HIPAA Administrative Simplification Compliance Act (ASCA) prohibits HHS from paying Medicare claims that are not submitted electronically after October 16, 2003.

However, small providers are exempt from the ASCA provision that excludes paper claims. Small providers are defined as a provider of services with fewer than 25 full-time equivalent employees, or a physician, practitioner, facility, or supplier (other than provider of services) with fewer than 10 full-time equivalent employees.

The advantage to filing Medicare claims electronically is that claims are normally processed within 14 days; Medicare, by law, cannot pay paper claims until 28 days after receipt.

Generally, claims must be filed within 1 year from the date of service to avoid a time-submission reduction. Claims filed after the deadline are normally subject to a 10% reduction on assigned claims or civil monetary fines for nonassigned claims. CP

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com )   and a chiropractic consultant. She can be reached via email: naca_csoyring@yahoo.com.