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

Part 1 of this article, which appeared in the April 2005 issue, discussed the fact that every year, Medicare makes us relearn new modifiers, new guidelines, new provider identifiers, new fees, and new deductibles. Part 2 continues discussing some items that are not so new, but yet are still misunderstood.

Adjusting Out of the Office
Chiropractors may 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 discount will be taken from the reimbursement. When the service is performed in the office, the place of service (POS) code is an 11. When the POS is something other than 11 (12 for home visit, or 32 for nursing home visit), then the site of service discount is in effect and the reimbursement rate is lower. Usually, the site-of-service discount is approximately $5 less than the normal allowable fees.

Diagnosing a Medicare Patient
Coverage for chiropractic manipulative therapy (CMT) codes are based on the use of the correct ICD-9-CM code(s). They are listed in primary order, and include a symptom with each level of segmental dysfunction/ subluxation. In box 21 of the claim form, the primary diagnosis must be listed as a segmental dysfunction/ subluxation, then a symptom associated with that region. In positions 3 and 4 of box 21, the symptoms or additional subluxations that are needed to support additional regions (billed (98941, 98942) must be listed. Additional codes may also be listed in box 19 if necessary. All diagnoses must be recorded in the patient’s chart with appropriate ICD-9 codes.

• Primary diagnoses must be listed in box 21, position 1; diagnosis codes must come from the 739 Series (739.1 through 739.5) segmental/somatic dysfunction.

• Secondary diagnoses must bear a direct relationship to the chronicity of the subluxation. Symptoms, complications, and/or associated ailments increase the likelihood of extended benefits. Secondary diagnosis codes must be from Medicare’s approved list of secondary diagnoses (category 1, 2, or 3).

Mandatory Claim Submission
Section 1848(g)(4) of the Social Security Act requires providers and suppliers to submit claims for covered services. Centers for Medicare & Medicaid Services (CMS) policy for filing Medicare Part B claims states that all claims for covered services rendered to Medicare beneficiaries must be submitted to the Medicare carrier.

Providers are not required to take assignment of Medicare benefits unless they are enrolled as a Medicare participating physician, or the Medicare beneficiary is a recipient of a state medical assistance program (Medicaid). Providers may not charge the beneficiary for preparing and filing the Medicare claim. Providers are not required to submit claims for noncovered services. However, if the beneficiary or his/her representative believes a service may be covered, or desires a formal Medicare determination for consideration by a supplemental insurance, the provider must submit a claim.

Duplicate Claims
Although duplicate claim submissions will occur from time to time, Medicare expects the rate of occurrence to be less than 1% of all claims processed. However, approximately 6% of all claims filed to Medicare Part B are denied as duplicate claims. Patterns of filing duplicate claims are considered a form of program abuse. According to CMS, abuse is defined as: “Intentionally or unintentionally filing duplicate claims to the Medicare program, even if it does not result in duplicate payment. Abuse may, directly or indirectly, result in unnecessary costs to the Medicare/Medicaid program.”

Timely Filing of Claims
Claims must be filed with Medicare by the end of the calendar year following the fiscal year—which runs from October to September—in which the services were provided, or the claim will be denied. If a claim is filed more than one year from the date of service, payment to the physician or supplier will be reduced for that service by 10%. The provider cannot bill the patient for this reduction. The patient may only be charged 20% of the amount that Medicare would have approved for the service.

Violations
The Medicare Fraud and Abuse Unit monitors physicians and suppliers to ensure compliance with the Medicare mandatory claim filing requirements. Physicians and suppliers who do not submit claims for beneficiaries, who charge for preparing and filing claims, and/or who charge the beneficiary the 10% reduction in the Medicare payment for untimely claim submission, may be subject to civil monetary penalties of up to $10,000 per violation.

Medicare as a Secondary Payor
There are certain instances when another insurance will pay before Medicare. These instances include:
    •    If the beneficiary or the beneficiary’s spouse is actively employed;
    •    If the beneficiary is disabled and under age 65, with employer benefit coverage;
    •    If there is Automobile, No-Fault Medical, Personal Injury Protection, or Third-Party Liability involvement;
    •    If Black Lung Program Benefits are paid by the Department of Labor’s Black Lung;
    •    If the beneficiary is entitled to Veterans benefits;
    •    If the beneficiary is injured on the job and covered under workers’ compensation; and
    •    If individuals are entitled to Medicare on the basis of End Stage Renal Disease (ESRD).

Immediate Relatives Are Medicare Exclusions
It is illegal for a provider to file a claim to Medicare when treating his or her immediate relatives. What most providers do not know is just how far Medicare defines “immediate relative.” Here is the list of exclusions, according to Medicare regulations: husband and/or wife; natural or adoptive parent, child, and sibling; stepparent, stepchild, stepbrother, and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law; grandparent and grandchild; or spouse of grandparent and grandchild. Furthermore, when a step-relationship exists, that relationship exists even after the marriage upon which the relationship is based is terminated through divorce or death. A brother-in-law or sister-in-law relationship does not extend to the in-laws, by marriage (in-laws of wife or husband of a provider). A father-in-law or mother-in-law relationship does not exist between the provider and his or her spouse’s stepfather or stepmother.

There is another exclusion, according to Medicare’s “immediate relatives” definition, that many providers overlook—and that 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, (live-in babysitters or domestic helpers). 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.