August 2011

August 1, 2011
“Chiropractic Medicare Fees and Collecting Payment”
Chiropractors are the only healthcare providers that CANNOT opt-out of Medicare. When you see seniors with Medicare in your practice you must do Medicare correctly!
Each Medicare carrier provides a fee schedule for the Chiropractors each year in each state local.  You can go to your Medicare Carrier's website search for Physician Fee Schedule (go to about page 245) and you will find 98940, 98941 and 98942 with specific fees for your local for both participating and non-participating providers.  The code with the # sign indicates the fees set for if you adjust this patient in another facility other than your office. The fees without the # sign are your in-office fees.
Participating providers may bill the Medicare Carrier whatever fee they wish.  The Medicare Carrier has the responsibility to know your Medicare fees and will automatically reimburse to the DC 80% of those fees.  The Chiropractor must collect the 20% from the patient or supplemental insurance and NEVER collect from any payor above the set fees by the Medicare Carrier. If you do, and get caught, the fines are up to $10,000.00 per incident.
A non-participating provider must know what the Medicare fees are prior to seeing or billing either the Medicare patient or the Medicare Carrier.  If they don’t and get caught, they may be fined up to $10,000.00 per incident and the same for being paid above the set Medicare fees.  The non-participating provider must never collect or bill any payor above the "limiting" charge, including a Medicare patient in auto accidents, worker’s comp., etc.
August 8, 2011
“Chiropractic Audits Gone Wild!”
Chiropractic Medicare Audits...Audits...Audits!

My phone calls are increasing especially from New York, California, Nevada, and now Alabama!

Palmetto Medicare Carrier in California and Nevada broke the ice and requested thousands of Chiropractic records as both pre-payment and post payments audits. Then, the New York Medicare Carrier went wild with requesting records on every patient.

Now the Alabama Medicare Carrier is following suit with audit after audit on Chiropractors, requesting records/documentation for a specific period of time and any portion of the preceding 6 months prior. 

These audits, first, eat up the small profits we get in Medicare. Secondly, they stress both the doctor and the staff effecting the quality of Chiropractic care delivered.  The major problem is that most Chiropractors lose some or their entire audit because of mistakes or lack of knowledge in Medicare procedures. 

Speaking with hundreds of Chiropractors dealing with audits, they all have made the following errors that cost them big time:
  1. Date of current (HCFA item #14) must never be over 60 days old.
  2. X-ray date must be less than 12 months old (364 days or less), or when no x-ray present, a P.A.R.T. form must be completed each and every visit. 
  3. Diagnosis must make sense and match S.O.A.P. Notes to support the care rendered.
  4. Lack of complete documentation by Federal Standard to proven Medical Necessity.
S.O.A.P. Notes are not the only Chiropractic documentation necessary to make a claim payable.  (Documentation is a federal document.)
August 17, 2011
“Other Payers on a Medicare Patient”
There are specific guidelines we all must know and follow as we see Medicare patients that have another primary payer other than Medicare (e.g. Workers Comp., Auto Insurance, Personal Injury.)  Keep in mind; we are required to bill Medicare for ALL covered services even if there is another payer.

As a Participating Provider, you may bill your normal PI fees on this Medicare patient to all other payers and collect above the Medicare fees from other payers. 

Non-participating Providers, even though they receive the highest reimbursement from Medicare (i.e. the limiting charge), you must NEVER bill or collect from any payer on this Medicare patient above the limiting charge. (The limiting charge is the amount your Medicare carrier has set for your local.)  Item 10a through 10c on the claim form or in the electronic billing format will tell the Medicare Carrier (and other payers) who is responsible for payment.

Make a copy of the claim to the primary payer other than Medicare e.g., Workers Comp., Auto Insurance, Personal Injury, etc., and also, send a copy of the claim to the Medicare Carrier.  Be sure when billing another payer on this Medicare patient, to have the patient sign an ABN each visit, for both covered and non-covered services and use all modifiers, since Medicare will not pay.  (Example:  98941 AT GA)

The advantage of billing Medicare on this PI claim is if the PI claim fails and your patient loses the case, now Medicare will pay most of the claim because it was billed within the year time limit with all the correct modifiers and fees.
Questions? Give me a call today at 1-800-MY CHIRO.
August 24, 2011
“P.A.R.T. Exam, X-ray, and the Demonstration of Subluxation”
One of the requirements for the initial visit is the diagnosis of a subluxation that corresponds to the symptoms the patient demonstrates.  In other words, these symptoms must bare a direct relationship to the level of subluxation. The diagnosis of subluxation can be made either by a dated x-ray or by a physical exam noting 2 of the 4 following criteria to support a manually demonstrated subluxation:
  1. Pain/tenderness evaluated in terms of location, quality and intensity.
  2. Asymmetry/misalignment identified on a sectional or segmental level.
  3. Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility.)
  4. Tissue, tone changes in the characteristics of contiguous or associated soft tissue, including skin, fascia, muscle and ligament.
**One of the two criteria documented must be either asymmetry or range of motion abnormality.
I strongly suggest doing spinal x-rays a minimum of once each year, instead of P.A.R.T.  Using your x-rays to determine subluxation is never challenged, where as anyone can challenge the findings of a subluxation with P.A.R.T.
If you have no x-ray of the area you adjusted, less than one (1) year old, you must do a P.A.R.T. form each Chiropractic visit.  Even if some of your examinations consist of the same procedures as in P.A.R.T., you must have a P.A.R.T. form each visit.  When you have current x-rays of your Medicare patient, no P.A.R.T. form is necessary.  P.A.R.T. should be placed in Item #19 on the claim form to tell the Medicare carrier you are using P.A.R.T. with this patient.
August 29, 2011
“Chiropractic Medicare X-Rays “

Medicare is an excellent Chiropractic program.  No other insurance company, PPO, HMO, etc., requires Chiropractic Philosophy, Science and Art as in the Medicare guidelines. Chiropractic Medicare was written by chiropractors (Dr. Day, Dr. Hulsebus, etc.)

There are two (2) parts to Chiropractic Medicare to make a mandatory claim:
    1. The Chiropractor must prove a vertebral subluxation.
    2. The Chiropractor must "document" the chiropractic necessity of care by "federal standards."

I strongly recommend doing x-rays on each Medicare patient.  (P.A.R.T. is weak and can be challenged, whereas, using your x-rays, you are the authority in regards to locating subluxations.) 

You must have a minimum of two views of each region you adjust (AP & Lateral).  The films must be of good quality and evidence of collimation.  The x-ray films must be on location or in a location the doctor has access too, as the Medicare carrier may request those films as they did at the beginning of Chiropractic Medicare.

I suggest doing the following x-rays on each Medicare patient each year.  (If the doctor proves vertebral subluxation by way of x-rays, then the Chiropractor must have a new x-ray that is not over 12 months old, or the Medicare claim will be denied.)
    1 14x36 AP full spine
    1 8x10 Lat. Cervical (including occipital)
    1 7x17 Lat. Thoracic
    1 7x17 Lat. Lumbar (including Sacrum and coccyx)

Chiropractic x-rays are important in that it helps locate vertebral subluxations, pathologies, etc., and they are mandatory for we Chiropractors that use them to prove a subluxation.
BOTTOM LINE: If you wish to learn how to do Chiropractic Medicare correctly, including "documenting" by federal standards, please consider ordering our Chiropractic Medicare DVD and booklet. It explains piece by piece every important step in doing and billing Chiropractic Medicare so there are no limits for the chiropractic adjustment. If you are audited you will have done Medicare correctly and win your audit. You and your staff will be very happy you have this important and mandatory information. I promise it will make a difference in your understanding of Medicare and how you bill Medicare.
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Keep in mind, Medicare is the only insurance type program that if done incorrectly is fraud, a felony, a fine and/or jail.

I promise you will be more than satisfied that you made the right decision to purchase this information or attend our presentation. Please give me a call if you have questions. 1-618-395-3162

Best regards,
Dr. Gary R. Street

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