I spent some time on LinkedIn the other day and got this message from a Chiropractor. He said:
“Hi Kat,
What I really need is to understand the Medicare billing process. I have some patients getting older and I have never done Medicare. I know they have a lot of rules and restrictions.”
So I thought I would share what my response was to him, for anybody who needs it.
The first thing I’ll enter here is a disclaimer. The Centers for Medicare & Medicaid Services are very specific about “Chiropractic Services”, but they are referring to spinal adjustments only. As we know, Chiropractors can perform Physical Therapy, and may have other services performed in their offices like massage therapy, acupuncture and so on. These things may potentially be covered by a secondary insurance, but Medicare isn’t going to tell you how to bill them to the secondary. So what I give you here is information from my own experience, and I’ll include links below so you can research the codes and modifiers for yourself with CMS rather than just taking my (or anyone else’s) word for it.
Check out my video on this topic:
Here’s my personal Medicare for Chiro billing cheat sheet that I put together for a Chiro client:
- Bill adjustments: 98940-98942 only. Use AT modifier for active treatment.
- Primary dx code must be subluxation (M99.00 through M99.05)
- Claims must include initial treatment date in box 15.
- Exams are not covered by Medicare but secondary might cover, so use mod 25 as appropriate.
- PT codes are not covered by Medicare but secondary might cover, so use mod 59 as appropriate.
- Use GY for all PT codes.
- Use GP for all PT codes.
Medicare Modifiers Defined:
- AT = Active Treatment. Use this modifier on CMT only and only for active treatment, when Medicare is expected to cover. Applies only to medically necessary spinal manipulation to correct subluxation. Must have primary dx of subluxation.
- GA = Use on adjustments done under maintenance care (not active treatment) when we do not expect Medicare to cover. Use indicates ABN (Advanced Beneficiary Notice) is on file and allows the provider to bill the patient if not covered by Medicare. Ensures that upon denial Medicare will assign financial liability to patient.
- GY = Item does not meet the definition of a Medicare benefit. Indicates that Medicare is expected to deny.
- GP = Outpatient physical therapy.
And here are some informative links for you:
https://www.cms.gov/medicare/medicare-general-information/bni/abn
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56273
https://www.medicare.gov/coverage/chiropractic-services
https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2148cp.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019downloads/R4440cp.pdf
Kat Jordan is the Owner of Orion Billing Services. With extensive experience in healthcare billing, Orion is well prepared to help with expert billing and collections. Call (727) 492-4801 for more information.
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