Doctor’s of Chiropractic should know they must enroll with Medicare if they wish to treat a Medicare patient. Unfortunately, there are some who are still not aware of this, so note that absolutely services can be performed on a Medicare patient without first enrolling with Medicare or completing a successful revalidation. As part of enrollment, Dc’s are required to have an active Provider Transaction Access Number (PTAN) to provide and bill for services rendered.

The enrollment process can be paper of electronic. The first steps may seem obvious, but DC must be licensed to enroll. Each provider must have an individual National Provider Identifier (NPI) number. If you are a provider running your own practice, which should have a state appointed Tax ID number, your clinic will also need to have an NPI number. Both are established through the National Plan and Provider Enumeration System (NPPES) website. As part of the NPI enrollment process, you create a username and password through the NPPES website. If enrolling with Medicare through the electronic portal (Provider Enrollment, Chain and Ownership System, also known as PECOS), the same username and password set up through NPPES will be used to access information in PECOS. This is because Medicare verifies the information you provide to them with what is contained in NPPES. Medicare currently prefers that all enrollments be performed through the PECOS system as it’s faster and more accurate.

If enrolling by paper, secure the following forms as needed from the Centers for Medicare and Medicaid Services (CMS) website:

• CMS-855I: Individual Physicians or Non-Physicians (the provider)
• CMS-855B: Clinics/Group Practices and Certain Other Suppliers (the office)
• CMS-588: Electronic Funds Transfer Form (EFT)
• CMS-460: Medicare Participating Physician or Supplier Agreement
• CMS-855R: Reassignment of Medicare Benefits

From the list above, if you wish to enroll with Medicare, you will have to provide one or more (or in some cases all) of the forms, either by paper or electronically. If submitting through the PECOS system, know that it does not provide the designated form numbers on the portal. Rather, a series of questions will determine which forms should be submitted based on the answers you provide.

Medicare will only pay 80% of the allowed amount, which is the agreed-upon fee schedule. When a provider enrolls with Medicare, whether participating or non-participating, they agree to the Medicare allowed amount that corresponds with their participation level. From that fee, they will pay 80% of services that they determine to be payable.

A QMB (Qualified Medicare Beneficiary) is an individual that has both Medicare and Medicaid coverage and has qualified for this coverage. It is in essence a “hardship” policy for the beneficiary, because when they qualify for this, they do not have to pay for their deductible, co-pays, or co-insurances.

To be clear – if you want to treat Medicare patients, you (as a Chiropractor) MUST be enrolled with Medicare in order to do so. If you do not want to treat Medicare patients, then you do not have to enroll.

The first step would be to contact your Medicare Administrative Contractor (MAC) and verify the patient’s benefits. This can also be done through the online portal for your MAC. Verify that the patient does or does not have Part B coverage. You may want to do this while patients are present so that they hear what you hear if they have questions. If the patient is in fact only Part A, then they will be a cash patient in your office. They will be responsible for services rendered, and you cannot bill Medicare for them (and neither can the patient).

Medicare can be a Primary or Secondary insurance for a patient. If you or the patient are not certain, you can. always ask the carrier during the verification process if they are the beneficiary’s Primary or Secondary.

Medicare Part B (Medical Insurance) covers manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor or other qualified provider.

Medicare does not cover other services or tests ordered by a chiropractor, including X-rays, massage therapy, and acupuncture: https://www.medicare.gov/coverage/chiropractic-services

When a carrier agrees to become a Medicare Advantage Carrier, they sign a contract with CMS and the guidelines that they will follow are determined at that time. The Part C carrier does not have to agree to using the Medicare Allowed amount (Fee Schedule). Or they can agree to using and following Medicare’s fee schedule. The best way to determine what guidelines and fees they follow is to verify the patient’s benefits and ask at that time whether they follow the Medicare fee schedule and other guidelines. You can also find their Medical Policies on their websites.

No. Supplements are not covered under drug coverage and are not covered at all when billed by a Chiropractor to Medicare. Chiropractors do not participate with Part D Medicare.

Yes. When they are billed together on the claim form, the provider that performed the manipulation will have their NPI number in box 24j – this should only be a Chiropractor. Then, the provider that prescribes the medication will have their NPI number in box 24j for the prescription. This should not be the Chiropractor, as prescriptions are outside of their scope of practice.

 Yes, a provider can change their participation status, but only at certain times. 1. During open enrollment, which is every year from mid-November to December 31st. 2. Within 90 days of submitting your original enrollment application with Medicare.

STOP! Not only does this not qualify as Non-Participating, but it is also illegal for a Chiropractor. You should not touch a Medicare patient if you are not enrolled with Medicare. If you are doing this, please contact the WCA for assistance on how to compliantly correct this issue and IMMEDIATELY stop treating Medicare patients until you are enrolled.

All Medicare covered services must be billed to Medicare, or the provider could face penalties. A non-par provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible. It is important to note that non-par providers may choose to accept assignment; therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS 1500 claim form. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.

Whether or not a non-par provider chooses to accept assignment on all claims or on a claim-by claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule.

You can find a copy of the Medicare Participating Provider Agreement at http://www.cms.gov/Medicare/CMS- Forms/CMS-Forms/downloads/cms460.pdf

Additional information is available in the Medicare Benefit Policy Manual (Chapter 15; Covered Medical and Other Health Services) at https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Medicare Claims Processing Manual (Chapter 12; Physician/Nonphysician Practitioners) at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Any Medicare claim submitted can be audited/reviewed; the non-participating (non-par) or participating (par) status of the physician does not affect the possibility of this occurring. CMS audits/reviews are intended to protect Medicare trust funds and to identify billing errors so providers and their billing staff can be alerted of errors and educated on how to avoid future errors. Correct coverage, reimbursement, and billing requirements are readily available to assist you in understanding Medicare requirements. An excellent way to stay informed about changes to Medicare billing and coverage requirements is to monitor MLN Matters articles at https://www.cms.gov/training-education/medicare-learning-networkr-mln/resources-training/mln-matters-articles.

Opting out of Medicare is not an option for a Doctor of Chiropractic. Note 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. For further discussions of the Medicare “opt out” provision, see the Medicare Benefits Policy Manual (Chapter 15, Section 40; Definition of Physician/Practitioner).

Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements. Specific details regarding documentation are in the Medicare Benefit Policy Manual (Chapter 15, Sections 30.5 and 240). Also, see the Medicare Claims Processing Manual (Chapter 12, Section 220).

There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html

The Social Security Act (Section 1862 (a)(1); see http://www.ssa.gov/OP_Home/ssact/title18/1862.htm) provides that Medicare will only pay for items or services it determines to be “reasonable and necessary,” and if those items or services can be shown to be “reasonable and necessary,” then those items or services are covered and will be paid by Medicare.

A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare- Administrative-Contractors/What-is-a-MAC

Wisconsin: Part A and B – National Government Services, Inc. – Jurisdiction 6 https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List

CMS controls the MACs, so you can always locate your MAC by state on the CMS website. Here is the link to the most current MAC map: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative- Contractors/Downloads/AB-Jurisdiction-Map-Jun-2019.pdf

For the majority of guidelines, yes, they are the same for every MAC. However, you will occasionally find that there may be a variance. For example: Most MACs state that they want ONLY the Segmental and Somatic Dysfunction Diagnosis Codes (M99.0X) in the Primary location of the Claim form, followed by any secondary diagnosis for that same region. But there are a few MACs that will also allow the Subluxation Diagnosis Codes (M99.1X) to be used as well.

The truth is, it depends. Not every Medicare Advantage Plan (Part C) follows the Medicare Modifier usages.

For example, you may find one that does not accept the use of the GA Modifier because they do not use the ABN or have one of their own. The best way to determine if a specific Medicare Advantage Carrier will or will not allow the use of the same Medicare Modifiers is to add these questions to your Verification process OR locate the Modifier or Reimbursement Policies on the carrier website.

Modifiers are part of the CPT coding system. CPT modifiers (also referred to as Level I modifiers) are used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Code modifiers help further describe a procedure code without changing its definition.

Medicare has some Modifiers that are specific for them:

AT Modifier
Used to indicate that the covered services billed are for active corrective treatment and the provider’s documentation supports medical necessity and Medicare coverage guidelines. For chiropractic services, the AT modifier would be appended to the spinal manipulation CPT codes 98940–98942 when active treatment is being performed and the documentation supports medical necessity and coverage requirements. If CPT codes 98940– 98942 are billed without a modifier, the claim will be denied by the system as not medically necessary.

GA, GX, GY and GZ Modifiers
These can be used by physicians, practitioners, or suppliers to indicate services that are expected to be denied because of lack of medical necessity or statutory exclusion, and those that do not meet the definition of any Medicare benefit. The modifier GX was created to report on a claim when a provider has issued an ABN voluntarily for noncovered services.

Below are the definitions of each modifier and their appropriate applications.

GA Modifier: Redefined as “Waiver of liability statement issued as required by payer policy” – Used to report when a mandatory ABN was issued to a beneficiary for a covered service that is not likely to be covered by Medicare due to medical necessity. This modifier is frequently used by Chiropractors to indicate that spinal manipulation is being provided as maintenance care. Medicare does not reimburse for spinal manipulation that is performed as maintenance care or does not meet for medical necessity.

GX Modifier: “Notice of liability issued, voluntary under payer policy” – Used to report when a voluntary ABN was issued for a service. The GX modifier would be appended in addition to the GY modifier.

GY Modifier: “Notice of liability not issued, not required under payer policy” – Should be used on all services that are statutorily excluded or do not meet the definition of any Medicare benefit. Providers do not have to submit claims for noncovered services (e.g., massage, therapy, x-ray, etc.) unless the beneficiary requests claims are submitted, or if a denial is needed for secondary insurance claims processing. Providers may voluntarily use an ABN form to advise beneficiaries of services that Medicare does not cover under any circumstances. Refer to the CMS Medicare Learning Network (MLN) Matters article MM6563, Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs).

GZ Modifier: “Item or Service Expected to Be Denied as Not Reasonable and Necessary” – Used when a provider does not expect a service to be covered by Medicare and does not have a valid ABN on file. Beneficiaries are not liable for payment of services when they were not notified prior to the services being rendered that the service would not be covered by Medicare due to medical necessity.

Routine or blanket ABNs are usually not permitted. An ABN should only be given to a Medicare beneficiary when the provider has reason to expect that Medicare will deny payment for some or all of the services. That reason should be listed on the ABN.

Therapy services provided by a chiropractor, although noncovered, must be submitted according to therapy guidelines. Therefore, please be sure to include one of the therapy modifiers defined below. Therapy services submitted without the appropriate modifier will be rejected as un-processable.

HCPCS Modifier GN: Services delivered under an outpatient speech-language pathology plan of care.
HCPCS Modifier GO: Services delivered under an outpatient occupational therapy plan of care.
HCPCS Modifier GP: Services delivered under an outpatient physical therapy plan of care.

Even though you may already know that Medicare covers 80% of the allowed amount, for services that are deemed Medically Necessary, you should still verify the patient’s benefits with Medicare (or ANY insurance). You will need to know if the Part B Deductible is met. You will also find out if the patient has a Secondary insurance that they have failed to mention. You may find out that the patient no longer has Part B but has enrolled in Part C Medicare. You may find out that the patient has Medicare as a Secondary. The patient may be confused or misinformed, and it is the responsibility of the office to ensure that claims are submitted properly to the carriers. Do not just assume that you or the patient knows.

LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC’s jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act: https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals#%3A~%3Atext%3DWhat%27s%20a%20%22Local%20Coverage%20Determination%2Cof%20the%20Social%20Security%20Act

To find an LCD by HCPCS code, press CTRL and the F key to open the “find” tool. Then, enter the HCPCS code. The code you are looking for will be highlighted. To view the LCD and/or Policy Article, simply click the link.

Yes, the appeal process is the same for every carrier. An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can appeal if Medicare or your plan denies:

• A request for a health care service, supply, item, or drug you think Medicare should cover.
• A request for payment of a health care service, supply, item, or drug you already received.
• A request to change the amount you must pay for a health care service, supply, item, or drug

https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal

Only Medicaid-certified chiropractors may be reimbursed for providing medically necessary Medicaid-covered chiropractic services to Medicaid recipients.

Manual Manipulations of the Spine

• Wisconsin Medicaid covers manual manipulations of the spine to treat spinal subluxation, as stated in Wis. Admin. Code HFS 107.15(2). Wisconsin Medicaid reimburses for manual manipulations of the spine only when the recipient’s diagnosis is subluxation.
• Wisconsin Medicaid covers one spinal adjustment per date of service per recipient.

Wisconsin Medicaid covers an X-ray or set of X-rays to:

• Assist in diagnosing spinal subluxation.
• Assess the existence of underlying conditions beyond the scope of chiropractic services. An X-ray(s) is covered only when performed on the same date as an initial office visit, per Wis. Admin. Code HFS 107.15(4)(a).
• Sectional views of multiple areas are covered if the diagnosis warrants multiple sectional views. Providers are required to use the most appropriate Current Procedural Terminology procedure code that describes the X-ray service performed.

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3).

Maintenance therapy includes services that seek to prevent disease, promote health, prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A).

MIPS is an acronym for the Merit-based Incentive Payment System implemented by the Centers for Medicare and Medicaid Services (CMS). MIPS incorporates aspects of the former Electronic Health Records (EHR) Incentive Program, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM) program. CMS is required by law to implement a quality payment incentive program, which rewards value and outcomes in one of two ways:

• Merit-based Incentive Payment System (MIPS) and
• Advanced Alternative Payment Models (APMs)

Under MIPS, providers are included if they are an eligible clinician type and meet the low volume threshold. Eligible clinician types include chiropractors, physicians, osteopaths, physician assistants, physical therapists, nurse practitioners, and more. The low volume threshold is defined as the volume of services and associated charges a provider must exceed in order to be MIPS eligible. Most chiropractors will not exceed the low volume threshold unless they operate within a large practice with a focus on Medicare patients. Therefore, most chiropractors will be exempt from participating in MIPS; however, interested chiropractors who exceed one of the three criteria of the low volume threshold may opt in to MIPS.

We strongly suggest you utilize the CMS Participation Lookup Tool to verify eligibility to participate in MIPS. Enter your NPI number to find out if you are required to participate in MIPS. Note: 2020 eligibility will not be available until February 2020.

Why
MIPS was designed to tie payments to quality and cost efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care.

When
The MIPS Performance Year begins on January 1 and ends on December 31 each year. Program participants must report data collected during one calendar year by March 31 of the following calendar year. For example, program participants who collected data in 2019 must report their data by March 31, 2020 to be eligible for a payment increase and to avoid a payment reduction in 2021.

Additional Resources
To assist providers with questions on MIPS, CMS has created a website, https://qpp.cms.gov, and has a designated email address and phone number for questions. You may email questions to qpp@cms.hhs.gov, or you can call 1-866-288-8292 to have a representative answer your question over the phone and send you an email response with your question and answer.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015.

MACRA created the Quality Payment Program that:

• Repeals the Sustainable Growth Rate (PDF) formula
• Changes the way that Medicare rewards clinicians for value over volume
• Streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS)
• Gives bonus payments for participation in eligible alternative payment models (APMs)

*MACRA also required us to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019.