ChiroCode receives and answers hundreds of Quick Questions each month
from our customers. Customers who purchase the ChiroCode Membership are able to email questions directly to the experts at
ChiroCode. Professionals who have chosen the ChiroCode Premium Membership may also contact our Quick Questions hot line for
ChiroCode accumulates the questions and answers
and adds them to the ChiroCode KnowledgeBase which is available to
Premium Memberss. Also ChiroCode features a new Quick
Question and Answer each week that appears on our home page along with the two prior questions. These questions and answers are also shown below. This page also contains the question portion from
prior week's Quick Questions. A full archive of all the ChiroCode Quick
Questions and Answers can be found in the ChiroCode KnowledgeBase.
If a PI patient has Medicare, do I have to bill Medicare first? Do I have to accept the Medicare price?
As of January 1, 2013, Medicare tells us that you can charge your regular fee and you should submit the claim to the PI carrier, worker's compensation, or group health plan first. If, however, there is a denial, it must be provided or Medicare will not pay and the patient may not be billed for the difference. Also, Medicare guidelines for pricing then apply. See Medicare Learning Network Matters article MM 7355. (special thanks for Mario Fucinari, DC MCS-P for this answer).
Q: Is there a simple formula that I can use to show "medical necessity" so my notes will stand up to a review?
A: While there is no catch-all, there is definitely a recipe that can be applied to most services and most payers. You can take any service done in your office and test it to see if it meets four criteria:
Is there a problem? Many payers don't want to pay for full spine adjusting if there is only a neck complaint. Be sure that there is a patient complaint for every area that has a procedure code associated with it. This is particularly true of Medicare.
Is there a cause? Can the doctor prove, objectively, that they can explain why the problem is there? Is the cause something that is within the scope of chiropractic care? For example, if the neck pain is due to a massive boil, it might not be covered when treated by a DC, but if it is facet syndrome, then you'd be okay.
Is there a plan? A plan is not simply a statement of the frequency and duration of care, but also a list a goals and measurable outcomes. If a patient presents with neck pain, and there is a plan created to address it, then it would not be acceptable to just throw in an extra-spinal adjustment or mechanical traction here or there to run up the bill. There must be a plan in place for each service delivered.
Is there progress? A plan that is put in place with goals, but never updated, is of little value. You must prove to the payer that the care is working by reaching goals and setting new ones. This can be done effectively with re-exams and outcome assessment tools.
Take a look at the services you billed for yesterday in your clinic. Ask yourself if these four criteria were met for each and every service. If so, then these services are likely to be considered "medically necessary", however, note that each payer has it's own specific rules and guidelines.
I am new to Medicare. Can I file a claim without an electronic submission method? What form do I use? Is it called the "HCFA"?
There is a new form that was released last fall. It was just an updated HCFA...now referred to as the "1500 claim form". You can purchase the forms from ChiroCode but you will need a software or type writer that will print on the forms.
We recommend considering a software that will allow you to file electronically. Turnaround is much faster and they are much easier to use. Also Medicare website cms.gov has a free program to fill out the claim forms.
I have a particular patient whose primary insurance is Medicare Railroad (which we are non-par with). This patient is a snowbird so he comes in for a few dates in the year. Every date of service is denied by Medicare RR with a request for supportive medical notes. Our notes have been denied and we are now being asked to appeal to Q2Administrators. The patient has recently come in again for the first time in 7 months and Medicare Railroad is asking for notes already. Should I keep billing to Medicare or just bill the patient? I am afraid of drawing red flags, which I feel we are doing by constantly appealing.
What are the allowable minutes needed when billing multiple 97110 exercises on a patient and what is the procedure for billing this code with a modifier 51 and 59? Also, how many units are normally allowed when performing these on one area of the body as opposed to 2 or three areas?
I am having a problem with XYZ Insurance paying us on 98943 codes. We added the modifier -59 to all of the codes but on every single EOB has the same response "charge considered as part of Per Diem payment made on this date". Am I using the wrong modifier and/or do I need to send in chart notes?
I have a Medicare patient who comes in for a few dates in the year. Every date of service is denied by Medicare with a request for supportive medical notes. Our notes have been denied and we are now being asked to appeal. The patient has recently come in again for the first time in 7 months and Medicare is asking for notes already. Should I keep billing to Medicare or just bill the patient? I am afraid of drawing red flags, which I feel we are doing by constantly appealing.
As I read the rules and regulations of HIPAA it appears that open treatment rooms (rooms where more than one unrelated patient is in the same room and can easily hear all the communications between the doctor and patient) violate HIPAA privacy rules because PHI will be overheard by others. Additionally, you cannot "over ride" this privacy issue with a Notice of Privacy Practice that grants permission for such PHI disclosers. Correct?
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