8 Misconceptions About Medicaid Chiropractic Billing

Is spinal manipulation a covered service under Medicare? Can Doctors of Chiropractic (DC) opt out of Medicare? Depending on who you ask within the chiropractic community, you’ll probably get a variety of answers to these questions and they might very well be inaccurate. That’s because when it comes to Medicare and its regulations as it relates to chiropractic services, there’s plenty of misinformation out there.

Thanks to the Department of Health and Human Services, we’ve got answers. Here are eight common misconceptions about Medicare and chiropractic billing the Centers for Medicare & Medicaid Services (CMS) has outlined, along with factual explanations to help clear the air. For more details regarding each of the following issues, see this handy and printable CMS fact sheet, from which we are sharing this information.

Misconception #1: There is a 12-visit cap or limit for chiropractic services.

Facts: 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 detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5.

Misconception #2: Non-participating (non-par) providers do not have to worry about billing Medicare.

Facts: Just because you’re a non-par doesn’t mean you don’t have to bill Medicare. All Medicare Part B covered services must be billed to Medicare by the provider (or the provider can face penalties). This is known as the Mandatory Claim Submission Rule.

One exception to this rule is when the beneficiary has signed a valid Advance Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, with Option 2 selected. To find out more about what a non-provider is, and how they can choose to accept assignments on claims, consult the CMS fact sheet.

Misconception #3: If you are a non-par provider, you will never be audited nor have claims reviewed.

Facts: Any Medicare claim submitted can be audited/reviewed; the participation status of the physician doesn’t affect the possibility of this occurring. CMS audits/reviews are intended to protect Medicare trust funds and also to identify billing errors so providers and their billing staff can be alerted of errors and education on how to avoid future errors.

Correct coverage, reimbursement and billing requirements are readily available to assist you in understanding Medicare requirements. For more details, explore Medicare manuals online at the CMS website.

Misconception #4: You can opt out of Medicare.

Facts: Doctors of Chiropractic (DC) may not opt out of Medicare. But understand that opting out and being non-participating are not the same things. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out. Opt out refers to physicians’ ability to decide not to bill Medicare at all and then entering into private contracts with Medicare beneficiaries they treat.

Services furnished under these private contracts that meet the opt out requirements are not covered services under Medicare and no payment is made for those services by Medicare. For more details about the opt out provision, see the Medicare Benefit Policy Manualon the CMS website.

Misconception #5: You should get an Advance Beneficiary Notification (ABN) signed once for each patient and it will apply to all services and visits.

Facts: Your decision to deliver an ABN to a beneficiary must be based on the expectation that Medicare will not pay for a particular service because that service will not be considered medically reasonable and necessary in this instance. The ABN then allows the beneficiary to make an informed decision about receiving and paying for the service.

The ABN has three option boxes, and the beneficiary must choose one before signing the ABN for it to be considered valid liability notification. For specifics about these three option boxes, see the CMS fact sheet. As the CMS explains, 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.

Providers may issue a single ABN to a patient receiving the same service multiple times on a continuing bases. ABNs for repetitive services must describe the specific service(s) and frequency of delivery. If delivery of the repetitive service exceeds one year or the service provided changes, a new ABN must be issued. For more information regarding ABNs, beneficiaries and other related issues, consult the Medicare Claims Processing Manual, Chapters 15 and 30. Or check out this Advance Beneficiary Notice of Noncoverage Interactive Tutorial.

Misconception #6: Maintenance care is not a covered service under Medicare.

Facts: Spinal manipulation is a covered service under Medicare. However, maintenance care is not considered by Medicare to be medically reasonable and necessary, and is not reimbursable by Medicare. Only acute and chronic spinal manipulation services are considered active care and may, therefore, be reimbursable.

For a definition of maintenance care therapy, see Chapter 15, Section 30.5.b. Of the see the Medicare Benefit Policy Manual. Here, you can also find out more important information about completing claims and how to identify acute and chronic adjustments, as opposed to maintenance adjustments.

Misconception #7: Non-par providers do not have the same documentation requirements as par providers.

Facts: Chiropractic care has documentation requirements. The participating status of the provider is irrelevant to the documentation requirements. Specific details regarding documentation requirements are also in the  Medicare Benefit Policy Manual, Chapter 15, Sections 30.5 and 240.

Misconception #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.