The Proper Way For a Chiropractor to Bill Medicare

The Proper Way For a Chiropractor to Bill Medicare

One question that we get all the time from people reaching out to us is: What is the proper way for a Chiropractor to Bill Medicare? In fact, we’ve been asked that question so many times, we decided to create an easy to follow guide that covers the basics of how to properly bill Medicare as a chiropractor.

Consider sharing this resource with your team to make sure that they understand the intricacies of how to properly submit claims to Medicare.

So, without further ado, here is our guide that covers many of the basic things you and your team need to know!

1. Choose the correct CPT code. Medicare only covers certain chiropractic services, so it is important to use the correct CPT code when billing. The three covered CPT codes for chiropractic services are:

  • 98940: Chiropractic manipulative treatment (CMT); spinal, one to two regions
  • 98941: CMT; spinal, three to four regions
  • 98942: CMT; spinal, five regions

2. Attach the appropriate modifiers. There are a few modifiers that may be used when billing for chiropractic services. These modifiers can help to clarify the type of service that was provided and the patient's condition. Some of the most common modifiers for chiropractic services include:

  • AT: Active/corrective treatment
  • GA: Waiver of Liability Statement Issued as Required by Payer Policy.

This modifier indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare. Use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability.

  • GY: Notice of Liability Not Issued, Not Required Under Payer Policy.

This modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded.

3. Provide clear and concise documentation. Medicare requires that chiropractors provide clear and concise documentation to support their billing claims. This documentation should include the following information:

  • The patient's chief complaint and secondary complaints including every area that is treated.

For instance, if the patient only complains of cervical neck pain, you could only bill for 1 treated region. Treating additional regions could cause denial in the case of medical review.

  • Concise documentation of all treatment provided.
  • Regular OATS assessments to monitor progress.
  • A detailed treatment plan with treatment goals.
  • Correct use of boxes 14 and 15 on the HCFA form

Box 14 should have the date of onset of current symptoms, with corresponding qualifier 431.

Box 15 should have the Initial Treatment Date, meaning the date you first treated the patient for their newest injury/symptoms, with corresponding qualifier 454.

4. Submit the claim to Medicare. Once the claim is complete, it can be submitted to Medicare for review. Medicare has a deadline for submitting claims. Be sure to submit your claims within 365 days of the date of service to ensure you receive payment. Claims that are not submitted timely must be written off and the patient cannot be charged.

Different types of Medicare Enrollment:

Participating Provider - In Medicare, “participation” means you agree to always accept assignment of claims for all services you furnish to Medicare beneficiaries. By agreeing to always accept assignment, you agree to always accept Medicare-allowed amounts as payment in full and to not collect more than the Medicare deductible and coinsurance from the beneficiary.

Non-participating Provider - accept Medicare but do not agree to take assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare’s approved amount for health care services as full payment.

Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services.

Providers still must submit the claims to Medicare. You can choose to accept or not accept assignment. If you do not accept assignment, Medicare will return payment directly to the patient.

Opt-out providers - do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so.

The provider must give patients a private contract describing their charges and confirming that the patient understands they are responsible for the full cost of care and that Medicare will not reimburse them.

Opt-out providers are not required to bill Medicare for services.

Be sure to check your enrollment type to ensure you are following the guidelines and submitting claims properly. By following these steps, chiropractors can ensure that they are properly billing Medicare for their services.

Please note that the above is meant as a basic guide to get you, and your team, started on your journey to understanding how to properly bill claims to Medicare. If you have more detailed questions, or if you just want someone to handle it for you, then consider reaching out to our team of experts for a consultation. We are here to help! Schedule a free discovery call here to learn more: https://calendar.app.google/hdvoec3TXcaMCKdj9

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