Medicare Article.

[Guest guest]

The following is a version of the article which should appear in the next CAO journal re. Medicare. I am told that all licensed DCs get the journal but i thought that you might want a printable version. Go ahead and print it and put it with you medicare stuff.

Greetings fellow DCs. I am the CAO's representative to Noridian (Oregon's Medicare -Part B-contracted r). I have learned alot in my 1st year in this volunteer position and I look forward to learning more and continuing to help our profession regarding Medicare issues.

Unfortunately, Oregon DCs are doing a less than exceptional job of informing themselves regarding Medicare billing policies and practices. About 75% of the problems DCs experience regarding Medicare exist because of basic lack of knowledge. On the other hand, Noridian, Medicare and HCFA have also done a less than exceptional job of communicating their policies to Oregon DCs and I have made this clear to them and will continue to do so. Yes, Medicare and Noridian are far from perfect, but it is not that bad a system once you take the time to learn to navigate it...and interestingly, this system is user-friendly to both vitalistic chiropractors and those DCs more orthopedically-oriented. The 65 and over population is rapidly growing and I believe we have to earnestly try to 'play their game'. If we don't, we will continue to get squeezed out of all types of health care insurance programs. I won't go into the subject of Medicare Part C (managed medicare), that will be the topic of my next article perhaps. I have spent alot of  time on the phone and exchanging e-mails with DCs who really don't know much about medicare. They always have the same questions...questions whose answers are easy enough to find. So, for this article, I thought I would take a little time to teach you "how to fish" for answers to common questions.

1) Every licensed DC whos sees a Medicare Part B beneficiary in their office must apply for a Medicare ID number. To not do so is against federal administrative rules and is perceived as unlawful or illegal. Once you have a medicare number, you are also required to submit billings to Noridian, even for care which does not qualify for coverage.

2) Every DC office should have a 1999 "Chiropractic Billing Manual" and the March 2000 "Special Mailing" of Medicare B news which are available by going to the website www.noridian.com/medweb . Also, keep these numbers handy: Local Medicare Information office (for answers to general policy/billing questions) 503-977-1207. The provider call center in North Dakota (for specific billing questions/problems) (toll-free) 877-908-8431.

3) Every DC should inform him/herself regarding the new way that Medicare qualifies a"subluxation" of the spine via the "P.A.R.T." criteria.

4) Inform yourselves regarding the proper use of primary (subluxation)and secondary ("pathology") diagnoses, it's easy.

5) Learn how to use the GA (which is attached to the CPT code) modifier. This is important folks. You can actually get audited by Medicare retroactively and be required to refund large amounts of money to beneficiaries if you do not properly inform them of the possibility that Medicare might not pay and have the patient initial that waiver at EVERY OFFICE VISIT.

6) The AT modifier is also of utmost importance. You use it when you commence or initiate a 'trial' of treatment. There has been much confusion in Oregon regarding the usage of this modifier. This is mostly Medicare and Noridian's fault, they are in the process of getting their policy straight and I am hoping that they will do some sort of special mailing with the proper information. Here is the correct way to use it: On the date of service where you initiate a trial of care for a given diagnosis you attach the AT diagnosis to the CPT code. You can also attach the GA modifier at the same time to the same CPT code). Disregard what the 1999 billing manual says regarding the AT modifier. The AT modifier is like a "starting gun" which starts a clock ticking on a therapeutic trial.  Line 14 on the claim form does the same thing basically. Medicare expects to see indications that the patient is improving over the following weeks and months (if appropriate). Medicare limits the number of AT modifiers that you can use per year, but they do not publish that number. I unofficially suspect it is 2 or 3 per year (unless you can prove the need for more, of course)

7) Know the difference between "participating" and "non-participating"...do not confuse these with "accepting assignment" of benefits and "not accepting. assignment". Familiarize yourself with the fee schedules and program them into your software for simplicity.

8) Learn to "think" more like Medicare. Remember, there is NO defined limit to the NUMBER of times a patient may be treated. Rather, like it or not, Medicare views chiropractic manipulation as a treatment intervention wherein there is a plan, a beginning and end and there is expectation and documented proof of reasonable progress. This is where it is very important to know the difference between "therapeutic" care, "supportive" care "maintenance/maintentive" and "wellness/preventative"care. Medicare only pays for "therapeutic" and supportive" care and nothing else. Prolonged (a month or more) high-frequency treatment (3x/week or more) with no tapering off of the treatment is a red-flag for medicare (unless you can reasonably show the need for it). A 'therapeutic trial" of care lasting longer than 4 months is a red-flag for medicare (unless you can demonstrate the need for it). Regularly scheduled monthly visits are a red-flag for medicare (unless you can show that they are "therapeutic or supportive".Familiarlize yourself with the various mainstream chiropractic guidelines that are out there.

I hope you find this article of some help in your dealings with Medicare. I will be at the CAO Spring Convention and look forward to talking with you regarding general Medicare/Noridian issues.

J. , DC

Springbrook Chiropractic Clinic

Newberg, Oregon

cdc@...

[Guest guest]

,

Thank you very much for your efficient overview of Medicare. It is indeed helpful to me.

I must admit that I resent the guessing game I have found Medicare to be. For example, you said:

" Medicare limits the number of AT modifiers that you can use per year, but they do not publish that number. I unofficially suspect it is 2 or 3 per year (unless you can prove the need for more, of course) "

Why must we " suspect " and surmise any aspect of Medicare? Why not simply state that it is 2, or 3, unless documented extenuating circumstances are presented?

Another issue which concerns me is that the senior population often needs fairly regular care to maintain their ability to reasonably carry on with the activities of daily living. This may look like maintenance care, even though it is not. Sometimes it simply works out that the need arises every 2 or 3 weeks. It isn't a matter of initiating care to correct a specific injury or condition which resolves over a predictable or anticipated period of time. These folks have degenerated spines, and they will need ongoing care at some frequency for the rest of their lives. Why can't we just acknowledge that, and either Medicare will pay for it or not?

Thanks for your good work.

Terry in Ashland

Medicare Article. The following is a version of the article which should appear in the next CAO journal re. Medicare. I am told that all licensed DCs get the journal but i thought that you might want a printable version. Go ahead and print it and put it with you medicare stuff. <snip>