A thorough explanation of the ever-changing Medicare system keeps DCs in the loop

Every year, it seems that we have to relearn the Medicare system. While the basics may stay the same, there is always a new twist to old rules. There are new modifiers, new guidelines, new provider identifiers, new fees, and new deductibles. This year, there is even going to be new coverage for a limited few.

What’s New
New Deductibles—as of January 1, 2005, the Medicare beneficiary’s deductible for Part B increased from $100 to $110. (The beneficiary’s premium’s also increased.) Chiropractic visits fall under Part B coverage (Part A is hospital coverage only, Part B is outpatient doctors’ visits and skilled nursing home care, and Part C is Medicare HMO coverage).

Deductibles are met with “covered services” allowable amounts only. In other words, because only manual manipulation is a covered service under Medicare, only the allowable amount set by Medicare for that service will be applied toward the deductible. For example, if your office files a claim to Medicare for $35 for manipulation, and the Medicare allowable amount is only $24.35 for your locality, then only $24.35 will be applied toward the deductible.

A Medicare patient can meet his or her deductible under Part B from any outpatient doctor’s visit, including annual eye examinations. Some patients carry a Medicare supplement that may pay for Part A deductibles, but not pay for Part B deductibles. Check secondary and supplemental policies carefully.

New Fees—Medicare fees change every year, usually by only pennies. Sometimes they increase, and sometimes they decrease. How much a doctor can charge a Medicare beneficiary depends on if the doctor is participating or nonparticipating, and if he or she has accepted assignment as a nonparticipating provider. This year, Medicare fees raised slightly across the board. To obtain a copy of the current fees for your locality, log on to: http://cms.hhs.gov/ or go directly to your state’s carrier Web site.

New Modifier—Medicare announced that claims filed on or after October 1, 2004, must contain the Acute Treatment (AT) modifier to reflect medically necessary manipulation services. If the AT modifier is not attached to CPT codes 98940, 98941, or 98942, the service will be considered maintenance therapy and will be denied. Additionally, billing staff should be aware of any local policy (local medical review policies/local coverage determinations) for these services that might limit the frequency or circumstances under which active/corrective chiropractic can be paid. If you exceed that limit, you shall not use the AT modifier.

New Expanded Coverage (for a select few)—The Centers for Medicare and Medicaid Services (CMS) announced a pilot program (Medicare Chiropractic Demonstration Project, Section 651 of the Medicare Modernization Act of 2003) to evaluate the feasibility and advisability of covering more services for chiropractors in the future. For this study, Medicare selected five states in which all services within the chiropractor’s scope of practice will be covered for approximately a 2-year period.

The Federal Register (dated January 28, 2005) described the demonstration services, methodology, and areas to be targeted. Basically, the study will be conducted in four geographic areas—two rural and two urban. The areas selected are the entire states of Maine and New Mexico, 17 counties in Virginia, 26 counties in Illinois, and Scott county in Iowa. For a complete list of the counties, go to www.cms.hhs.gov/researchers/demos/eccs/default.asp. This project is slated to begin April 1, 2005 (no fooling!).

New Provider Identifier (NPI) Numbers—While this change is not mandatory until 2007, providers should be aware of the plan. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has mandated a standard unique health identifier number for health care providers. The final rule was published in 2004, and providers may begin to apply for their new number in May 2005. This new NPI number will replace the various identifying numbers now used for different carriers (BC, Medicaid, Medicare, and Champus). The new numbers are expected to be 10 digits long—nine numeric with one alpha letter. As with all HIPAA regulations, NPI numbers will first become mandatory for covered entities only.

No More Grace Period—Health care common procedure coding system (HCPCS) codes (Level I CPT-4 and Level II alpha-numeric) are updated annually. Each October, CMS releases the annual HCPCS file to carriers. Previously, CMS had permitted a 90-day grace period for billing discontinued codes for dates of service from January 1 through March 31. However, since HIPAA requires that medical codes must be date-of-service compliant, effective January 1, 2005, CMS will no longer allow a 90-day grace period for providers to use in billing discontinued HCPCS codes. The elimination of the grace period applies to the annual HCPCS update and to any midyear coding changes.

What Is Not So New, But Still Misunderstood Advance Beneficiary Notice
Providers are required to have Medicare patients sign an Advance Beneficiary Notice (ABN), before services are furnished, if the provider believes that Medicare is likely to deny payment for an otherwise covered service (manipulation only). ABNs are not required for noncovered services. ABNs notify beneficiaries about receiving services for which they may have to pay out of pocket. Form ABN (CMS-R-131) became mandatory as of October 1, 2002. This form is a standard form, with mandatory language, and cannot be modified. To obtain a copy of the mandatory ABN, log on to http://www.cms.gov/medicare/bni/CMSR131G_June2002.pdf.

Medicare Modifiers
Sure, there is the new AT modifier, but what about all the other Medicare Modifiers? GA, GY, GP, GZ, G0283? Gee, I am so confused!

Medicare regulations state that providers must use distinct modifiers when billing services to Medicare carriers. These modifiers should be standard nationwide.

The GA modifier must be used when a provider wants to indicate to the carrier that they expect that Medicare will deny a covered service as not reasonable and necessary, and the provider has an ABN signed by the beneficiary. A GA modifier is only used in conjunction with a 98940, 98941, or 98942 code.

The GP modifier is used on all physical therapy codes. When a physical therapy code is billed to Medicare (perhaps for a denial for a secondary carrier, or just because it is billed) the appropriate way to bill is with the modifiers GPGY (meaning “therapy”/“noncovered service”).

The GY modifier must be used when a provider wants to indicate that the item being billed is statutorily noncovered, or is not a Medicare benefit. Chiropractors must use the GY modifier if they are billing any service other than manual manipulation to a Medicare carrier. GY modifiers would be used on examinations, x-rays, or therapy. (Note that on therapy codes there are two modifiers, GP and GY; however, on all other noncovered services, only the GY is necessary.)

The GZ modifier must be used when a provider wants to indicate to the carrier that they expect that Medicare will deny a covered service as not reasonable and necessary, and the provider does not have an ABN signed by the beneficiary. (Why would this ever happen? It is just a Medicare rule.)

G2083 is not a modifier. It is a HCPCS code for electrical therapy. Since Medicare recognizes all level II codes as a preference to CPT, the code G2083 should be used instead of 97014 when billing this service to Medicare. The complete code would be G2083-GPGY because it is also a therapy code and a noncovered service.

There are also two “Q” modifiers: QB—rural, underserved area, and QU—urban, underserved area. These modifiers are used if the doctor is practicing in what Medicare distinguishes as a health care professional shortage area (HPSA). 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.