Running a successful chiropractic office also requires a clear understanding of coverage standards of Medicare or other private payers and how to bill for those services. Chiropractic offices as well as medical billing companies should stay up to date with the billing and coding changes as well, as improper billing can not only result in claim denial but may also lead to penalties. A real example for this discussed in The Gazette, is the case of an Oelwein chiropractor, who has agreed to pay $79,919 to resolve allegations of improper Medicare and Medicaid billing in March 2018. This chiropractor is alleged to have violated the False Claims Act by improperly billing Medicare and Medicaid for chiropractic adjustments after providing free electrical stimulation.

CMS’ Fact Sheet explains that it covers only manual manipulation of the spine by chiropractors. No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered. Even though orders for performing X-rays or other diagnostic tests can be used for claims processing purposes, Medicare does not cover them when performed by chiropractors. It is also recommended that claims must include a primary diagnosis of subluxation and a secondary diagnosis reflecting the patient’s neuromusculoskeletal condition. The patient’s medical record must support the services submitted.

Misconceptions and Facts

The Centers for Medicare & Medicaid Services (CMS) has clarified certain common misconceptions and facts related to chiropractic billing.

In performing manual manipulation of the spine, some chiropractors use manual devices that are handheld with the thrust of the force of the device being controlled manually. While such manual manipulation may be covered, there is no separate payment permitted for use of this device.

  1. There is a limit on the number of therapy caps for chiropractic services.
    Fact – Medicare Benefit Policy Manual, Chapter 15, Section 30.5 explains that there are actually no limits or caps in Medicare for covered chiropractic care provided by chiropractors, as long as they meet Medicare’s licensure and other requirements.
  2. Non-participating (non-par) providers do not have to worry about billing Medicare.
    Fact – Whether you are a non-participating (non-par) provider or not, all Medicare covered services must be billed to Medicare, or the provider could face penalties. This is referred to as Mandatory Claim Submission Rule. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. However, their Medicare reimbursement is five percent less than a participating provider.
  3. As a non-participating (non-par) provider, you will never be audited nor have claims reviewed
    Fact – Any Medicare claim submitted can be audited or reviewed, irrespective of the nonparticipating (non-par) or participating (par) status of the physician. CMS audits/reviews aims at identifying billing errors. Correct coverage, reimbursement, and billing requirements are readily available to help providers understand Medicare requirements.
  4. You can opt out of Medicare
    Fact – Opting out of Medicare is not an option for Chiropractic doctors. Opting out is entirely different from being non-participating. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out. By opting out, physicians will be able to decide not to bill Medicare at all and then enter into private contracts with Medicare beneficiaries they treat.
  5. Get an Advance Beneficiary Notification (ABN) signed once for each patient, and it will apply to all services, all visits
    Fact – To deliver an ABN, there must be a genuine reason like – Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The ABN then allows the beneficiary to make an informed decision about receiving and paying for the service. If the beneficiary decides to receive the service, providers must submit a claim to Medicare even though you expect the beneficiary to pay and you expect that Medicare will deny the claim. 

    According to CMS, an ABN is issued each time a patient receives a Medicare covered service that the provider believes might be considered not medically reasonable and necessary and thus not payable by Medicare. A single ABN can be issued to a patient receiving the same service multiple times on continuing bases. ABNs for repetitive services must describe the specific service(s) and frequency of delivery. A new ABN must be issued, if delivery of the repetitive service exceeds one year or the service provided changes.

  6. Maintenance care is not a covered service under Medicare
    Fact – As per Chapter 15, Section 30.5.B. of the Medicare Benefits Policy Manual, maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. Though spinal manipulation is a covered service under Medicare, maintenance care is not medically reasonable and necessary and therefore not reimbursable by Medicare. Acute, chronic, and maintenance adjustments are all “covered” services, but only acute and chronic services are considered active care and may, therefore, be reimbursable.
  7. Non-par providers do not have the same documentation requirements as par providers
    Fact – Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements. Required documentation also includes Evaluation and Plan of Care, Certification and re-certifications, Progress Reports, Treatment notes for each treatment day and more.
  8. DME ordered by a DC will be reimbursed by CMS
    Facts – A chiropractor may act as supplier of durable medical equipment (DME) if s/he has a valid supplier number assigned by the National Supplier Clearinghouse, but a chiropractor will not be reimbursed if s/he orders DME.

 
As Medicare only pays for active treatment of acute or chronic subluxations, it is important to submit claims for active treatment with HCPCS modifier AT. But Medicare does not cover maintenance therapy; do not submit claims for maintenance therapy with HCPCS modifier AT. However, there is hope for more chiropractic treatments to get Medicaid coverage. There were reports that in June 2018, a bill was approved by Missouri Legislature that would allow Medicaid patients to get treated by a chiropractor, a service that is not currently available to them. The measure will help ease the opioid crisis and save the state millions of dollars by offering a less expensive alternative to Medicaid recipients with back pain.

A recent study published in JAMA Network Open has found that expanding beneficiary access to non-pharmacological treatments such as physical therapy, chiropractic, and acupuncture services may allow payers to provide clinically-proven solutions for temporary pain without relying on opioid prescriptions. Chiropractic billing services help to improve the revenue cycle for chiropractors by submitting accurate claims for all their services such as examinations and evaluations, adjustments and manipulation of the spine, and pain management.